In California Workers’ Compensation, Insurance Companies have an obligation to provide medical care. This medical care is provided by authorizing vendors to provide services. These services can include anything from medical treatment, hospitalization, durable medical equipment, home care, and prescription medications. One of these vendors that Insurance Companies utilize is Express Scripts Network Pharmacy.
This article will discuss the nature of prescription drugs within the California Workers’ Compensation System, how doctors are to prescribe drugs, why there is a denial of prescription drugs and how prescription denials are appealed, and how Express Scripts Network Pharmacy takes part in this process.
What is Express Scripts Pharmacy?
According to the company “Express Scripts is a prescription benefit plan provider that makes the use of prescription drugs safer and more affordable for our members. Express Scripts handles millions of prescriptions each year through home delivery from the Express Scripts Pharmacy.” Per Forbes, Express Scripts are considered as being in the business of pharmacy benefit management. The services include network-pharmacy claims processing; home delivery pharmacy services, and specialty pharmacy benefit management. Per Forbes “the company processes pharmaceutical claims for members through a network of retail pharmacies. Its own automated pharmacies dispense medications for chronic long-term diseases, such as diabetes or heart disease, directly to members by home delivery”
In California, large Insurance Carriers, such as the State Compensation Insurance Fund, employ Express Scripts to fulfill their obligation to provide prescription medications to Injured Workers.
Are There Prescriptions in Workers’ Compensation?
Yes and No. While Physicians may prescribe medications, the Physicians are required to place in a “Request for Authorization” (RFA) for prescription medication. This “Request for Authorization” is subject to approval by the Insurance Carrier via a Utilization Review (UR) Process. Further, if there is a denial of the medication prescription by the UR Process, the Injured Worker can seek an appeal via an Independent Medical Review (IMR) Process.
What Is the Utilization Review Process?
Per the California Department of Industrial Relations, “[u]tilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers’ compensation claims administrators are required by law to have a[n] UR program. This program is used to decide whether or not to approve medical treatment recommended by a physician which must be based on the medical treatment guidelines.
What is the Independent Review Process?
Per the California Department of Industrial Relations, “California’s workers’ compensation system uses a process called independent medical review (IMR) to resolve disputes about the medical treatment of injured employees. As of July 1, 2013, medical treatment disputes for all dates of injury will be resolved by physicians through an efficient process known as IMR, rather than through the often cumbersome and costly court system.
A request for medical treatment in the workers’ compensation system must go through a “utilization review” process to confirm that it is medically necessary before it is approved. If utilization review denies, delays or modifies a treating physician’s request for medical treatment because the treatment is not medically necessary, the injured employee can ask for a review of that decision through IMR.”
How Do I Know That Express Scripts Will Be Providing Me Medications?
Your Insurance Carrier provides you many notification forms. If they are utilizing Express Scripts as a vendor, they will notify you to that effect. Again, there are a number of carriers that employ Express Scripts as a vendor to provide medications to Injured Workers.
If the Insurance Company Handling My Claim Employs Express Scripts, What Should I Expect?
If the Insurance Carrier handling your claim employs Express Scripts, you can expect that you will be contacted to receive an Express Scripts prescription ID card. You will be allowed to use the prescription ID card to fill prescriptions at participating pharmacies. You can contact Express Scripts Customer Service at 1-800-945-5951 to speak to a patient care advocate. If there is the desire to obtain medications by mail, you should discuss that with Express Scripts.
What If I Need Advice?
If you would like a “free” consultation concerning any workers’ compensation case, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. They have been helping people in Central and Southern California deal with their worker’s compensation cases for 28 years. for more information.