Workers’ compensation covers medically necessary prescription medications for work-related injuries. The New York Medication Formulary provides an extensive list of drugs a doctor can prescribe for injuries and illnesses based on which body part is affected. Unlisted medications may also be covered if your doctor obtains pre-authorization. If workers’ compensation refuses to cover the medication you need, our experienced New York workers’ compensation lawyers can help.
Does Workers’ Comp Cover Medication?
Workers’ compensation covers the entire cost of necessary treatment for your work-related injury or illness, including medication. Our guide on how workers’ compensation works in New York City provides information on filing your workers’ compensation claim, getting a doctor, and obtaining coverage for your medical care, which includes prescription medications.
To receive coverage, your workers’ compensation doctor must prescribe it, and the medication must be considered medically necessary. Workers’ compensation insurers often disagree with doctors on the medical necessity of medications and deny coverage. Your doctor must follow specific requirements before prescribing some drugs, such as obtaining pre-authorization or trialing a different drug first.
Understanding New York Formulary Guidelines
The New York Medication Formulary comprehensively lists workers’ compensation prescription requirements. New York has uniquely structured the Formulary rules to balance patient care with cost-effectiveness. It specifies which medications can be prescribed to treat specific body parts, the duration of prescriptions, when medications can be prescribed, and dosages.
The Formulary classifies drugs into three phases:
- Phase A drugs – Medications that may only be prescribed during your initial treatment with a 30-day supply limit.
- Phase B drugs – Medications that may be prescribed after the initial 30-day treatment period with a supply of up to 90 days.
- Perioperative drugs – Medications that may only be prescribed four days before or after surgery.
Some drugs are designated as second-line drugs. These drugs are only considered formulary if your doctor tries another drug first. Certain drugs have additional restrictions, known as special considerations, which further limit how long your workers’ comp doctor can prescribe them. For example, some narcotics can only be prescribed as a single seven-day supply.
How to Ensure Your Prescriptions Are Covered
Workers’ compensation may make it difficult to obtain drug coverage even when you truly need the medication. You can help boost your odds of approval by doing the following:
- Choose a doctor authorized by the New York Workers’ Compensation Board or in your insurer’s Preferred Provider Organization (PPO).
- Attend all of your appointments.
- Follow treatment as prescribed.
- Report all symptoms and improvements to your doctor.
- Use an authorized pharmacy if your insurer uses an independent pharmacy, pharmacy network, or pharmacy benefit manager.
- Keep detailed records of your prescriptions, conversations with your doctors, and treatment notes.
Your doctor plays an important role in ensuring your prescriptions are covered. The doctor must only prescribe drugs to treat your work-related condition and may need to note how it is related when prescribing. The doctor must prescribe medication according to the New York Medical Treatment Guidelines, an official set of standards for workers’ compensation doctors. The doctor must be familiar with the Formulary or refer to it when prescribing medication to ensure the medication, timing, and dosage comply with the guidelines.
Pre-authorization for Certain Medications
You may be able to obtain coverage for medically necessary non-formulary drugs, but your doctor must obtain pre-authorization from the insurer or pharmacy benefits manager. Non-formulary drugs include the following:
- Drugs not listed on the Formulary.
- A brand name of a listed drug when a generic is available.
- A brand name drug when a generic is available in a different dose.
- Combination drugs, unless the specific combination is listed.
- Compounded drugs.
The insurer must respond to the pre-authorization request within four days. Failure to respond within this time frame could be treated as an approval. A pre-authorized drug can be approved for up to 365 days as necessary for long-term illnesses and permanent damage. Some drugs have shorter time frames, such as 30 days.
Steps to Take If Your Prescription Is Denied
Insurance companies look for any excuse to deny benefits. No matter how much you need a medication, workers’ compensation may give the following reasons for denying coverage:
- The prescription is not directly related to the workplace illness or injury.
- The drug is not medically necessary.
- The medication required pre-authorization, and the doctor did not obtain it.
- There is a less expensive generic version available.
If a pre-authorization request is denied, your doctor can submit the request for a Level Two review with the insurer. If the insurer denies the pre-authorization request, the physician can request a Level Three review with the Board’s Medical Director’s Office. This decision is considered final.
If your doctor fails to obtain pre-authorization or if workers’ compensation denies coverage for a formulary drug, work with your doctor to find an alternative medication. If the denied medication is your best or only option, seek help from a reputable workers’ compensation law firm. Our attorneys can handle communication with the Workers’ Compensation Board, represent you at hearings, and file a formal appeal.
How Shulman & Hill Can Help With Workers’ Compensation Claims
We are a community-centered workers’ compensation law firm with over a decade of experience protecting injured workers’ rights. We have helped hundreds of clients reverse unfair denials in workers’ compensation claims, including claims involving prescription drugs. We understand how important it is to get the right medication specific to your unique needs. We’re dedicated to providing compassionate, personalized support and getting you maximum results. Contact us online or call (212) 221-1000 to schedule a free consultation.
