Basics of Ohio Workers’ Compensation Prescription Drug Coverage

Ohio workers' comp prescription coverageWorkers injured on the job or suffer from a work-related illness often need prescription medications to manage their conditions. Many prescription drugs are covered by workers’ compensation, but, as with other treatments, the medicines must be approved by the Ohio Bureau of Workers’ Compensation (BWC), and you have to follow its required process to get your prescriptions filled.

Your BWC-certified physician should know the restrictions and requirements regarding prescription drug coverage, but it’s a good idea for you to understand how the coverage works, too. Let me explain the basics.

Getting the Medications You Need When You Need Them

Injuries sustained in an accident at work—such as falling off a ladder or throwing out your back while lifting something—are sudden and apparent. You probably needed help from a co-worker or supervisor and may have been treated onsite by a company doctor. Other times, debilitating injuries develop over time and make it harder to prove that the condition is work-related.

Either way, you may need medications such as painkillers immediately, and be able to get them under the BWC’s First Fill Program. Under this program, you can receive the first ten days of a prescription before your workers’ comp application is approved. The prescribing doctor will need to confirm that the medication is on the BWC’s approved list and must write “for work-related injury” on the prescription.

Your Medication Must Be on the BWC’s Pre-Approved List

The BWC’s outpatient medication formulary is a list of drugs it will cover when prescribed for an allowed condition on an approved claim. The list is reviewed and updated regularly. Your physician should make sure a medication on the formulary before prescribing it to you. With real medical necessity, a drug that's not listed on the formulary may be covered for up to 180 days if there's no other drug available to treat the condition. Any doctor can submit a request to have a new drug reviewed for possible inclusion in the formulary by filling out the appropriate paperwork.

Most common medications, or their generic equivalents, are included in the formulary, including anti-inflammatory drugs, muscle relaxants, anticonvulsants, antidepressants, acetaminophen, and topical products such as lidocaine and diclofenac.

If a name brand drug is requested where generics are available, the BWC may pay only part of the cost, leaving you liable for the balance. In particular situations, the BWC may instead opt to pay for the name brand minus fifteen percent.

As of December 31, 2019, the BWC no longer covers the opioid painkiller OxyContin. Because of the addictive nature of the drug, and the danger of overdosing, the BWC removed it from the formulary. Other opioids, such as Xtampza ER, are still allowed when prescribed by a physician.

Getting Reimbursed for Out-of-Pocket Expenses

If you pay for medication out of pocket, or it is billed to your private insurance, you should be reimbursed by the BWC after your workers’ comp claim is approved. Be sure to keep a copy of the paid receipt and the prescription information (usually attached to the bag) as it provides the name of the doctor, the prescription name, dosage, and cost. Only medications prescribed by a licensed physician and dispensed by a BWC-enrolled pharmacy will be refunded, and only according to the BWC’s fee schedule—not necessarily what you paid for them. You'll have to submit a separate C-17 form for each pharmacy you used within a year of the date your prescription was first filled to be considered for reimbursement.

New Prescription for Old Conditions

If you've been on workers’ comp for years and you or your doctor wants to try a new medication, you must get approval from the BWC. This process is similar to getting support for an additional allowance. You need to provide clear and convincing evidence for the new medication, especially if it's a controversial or expensive drug. Also, a prescription card may go dormant if unused and need to be reactivated.

Monast Law Office Can Help With Prescription Approvals

If you're struggling to get medication paid by workers’ comp, contact my office to talk with a member of our team. We've worked with hundreds of injured workers over the years and are familiar with a range of medications. Whether you're seeking reimbursement for the medication you paid for yourself, or are having trouble getting a necessary drug approved by the BWC, we may help.

To learn more about your right to workers’ compensation, request a free download of our book, The Worker’s Guide to Injury Compensation in Ohio

 

James Monast
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Fighting for Ohio’s Injured Workers and their Families