Will you be able to get free prescription medicines filled if you were injured on the job under the new Workers’ Compensation Law? As of July 11, 2007, the law specifically authorizes pharmacies to direct bill the insurance carrier and requires the insurance carrier to pay for the prescription or reimburse the employee injured on the job within 45 days of receipt of the claim for payment or reimbursement. It also allows the insurance carrier to contract with a pharmacy or pharmacies and require injured on the job employee to use the pharmacy or pharmacies to obtain their prescriptions. The only exceptions are when a medical emergency occurs and it is not reasonably possible to obtain immediately required prescribed medicines from such pharmacy or pharmacies or the pharmacy or pharmacies do not offer mail order service and do not have a physical location within a reasonable distance from the claimant. Pharmacy Fee Schedule and Pharmacy Benefit Management (PBM) Questions and Answers
Injured Worker Questions about workers compensation prescription reimbursement
| 1. I need a pharmacy card. Where can I get one? | Please contact your claims adjuster with the WC insurance carrier or contact your self‐insured employer. |
| 2. I have a problem with filling my drug prescription. My pharmacy is unable to fill the prescription. | Please contact Valuecare Pharmacy. |
| 3. My prescription was not filled and the claims adjuster is refusing to approve the prescription. What should I do? | File a RFA‐1W (Request for Assistance) form. This RFA‐1W form can also be filed online. Once this form has been filed, a hearing to resolve your prescription issues by a WC law judge will be scheduled. |
| 4. The pharmacy is asking for a BIN number/approval number in order to process the prescription. What should I do? | Please contact Valuecare pharmacy or claims adjuster/employer should contact the pharmacy directly. |
| 5. I had to pay for some of the drug prescriptions out‐of‐pocket. What should I do? | A. Submit your prescription and receipt to your claims adjuster/ self‐insured employer so that you can claim for these expenses. OR B. File a RFA‐1W (Request for Assistance) form together with your prescription and receipt. This RFA‐1W form can also be filed online. . |
| 7. I did not use the pharmacy designated by my carrier/self‐insured employer. I have a pharmacy card. | If you have received notification to use a pharmacy/pharmacy network, the carrier/self‐insured employer may not be liable to pay for the pharmacy bill. |
| 8. I did not use the pharmacy designated by my carrier/self‐insured employer. I was not notified to use a pharmacy/pharmacy network and I do not have a pharmacy card. | The carrier/self‐insured employer shall pay a bill or reimbursement request submitted by the pharmacy or its billing agent. |
| 9. I was not notified to use a pharmacy/pharmacy network and the carrier/ self‐insured employer is refusing to pay for my pharmacy bill. OR 10. I did use the recommended/notified pharmacy/pharmacy network, but the carrier/ self‐insured employer is refusing to pay for my pharmacy bill. | File a RFA‐1W (Request for Assistance) form together with your prescription and receipt. This RFA‐1W form can also be filed online. |
| 11. I was notified to use mail‐order/internet pharmacy service even though there is a pharmacy near my residence. Is this allowed? | Yes, the carrier/employer can require you to use the mail‐order/internet pharmacy service. Please contact your claims adjuster for details. |
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