Current through Reg. 49, No. 38; September 20, 2024
(a) It may become necessary for an injured
employee to purchase prescription drugs or over-the-counter alternatives to
prescription drugs prescribed or ordered by the treating doctor or referral
health care provider. In such instances the injured employee may request
reimbursement from the insurance carrier as follows:
(1) The injured employee shall submit to the
insurance carrier a letter requesting reimbursement along with a receipt
indicating the amount paid and documentation concerning the prescription. The
letter should include information to clearly identify the claimant such as the
claimant's name, address, date of injury, and social security number.
Documentation for prescription drugs submitted with the letter from the
employee must include the prescribing health care provider's name, the date the
prescription was filled, the name of the drug, employee's name and dollar
amount paid by the employee. As examples, this information may be provided on
an information sheet provided by the pharmacy, or the employee can ask the
pharmacist for a print out of work related prescriptions for a particular time
period. Cash register receipts alone are not acceptable.
(2) The insurance carrier shall make
appropriate payment to the injured employee in accordance with §134.503,
or notify the injured employee of a reduction or denial of the payment within
45 days of receipt of the request for reimbursement from the injured employee.
If the insurance carrier does not reimburse the full amount requested, or
denies payment the carrier shall include a full and complete explanation of the
reason(s) the insurance carrier reduced or denied the payment and shall inform
the injured employee of his or her right to request medical dispute resolution
in accordance with §
133.305 of
this title (relating to Medical Dispute Resolution). The statement shall
include sufficient claim-specific substantive information to enable the
employee to understand the insurance carrier's position and/or action on the
claim. A general statement that simply states the carrier's position with a
phrase such as "not entitled to reimbursement" or a similar phrase with no
further description of the factual basis does not satisfy the requirements of
this section.
(b) An
injured employee may choose to receive a brand name drug rather than a generic
drug or over-the-counter alternative to a prescription medication that is
prescribed by a health care provider. In such instances, the injured employee
shall pay the difference in cost between generic drugs and brand name drugs.
The transaction between the employee and the pharmacist is considered final and
is not subject to medical dispute resolution by the division. In addition, the
employee is not entitled to reimbursement from the insurance carrier for the
difference in cost between generic and brand name drugs.
(1) The injured employee shall notify the
pharmacist of their choice to pay the cost difference between generic and brand
name drugs. An employee's payment of the cost difference constitutes an
acceptance of the responsibility for the cost difference and an agreement not
to seek reimbursement from the carrier for the cost difference.
(2) The pharmacist shall:
(A) determine the costs of both the brand
name and generic drugs under §
134.503 of
this title, and notify the injured employee of the cost difference
amount;
(B) collect the cost
difference amount from the injured employee in a form and manner that is
acceptable to both parties;
(C)
submit a bill to the insurance carrier for the generic drug that was prescribed
by the doctor; and
(D) not bill the
injured employee for the cost of the generic drug if the insurance carrier
reduces or denies the bill.
(3) The insurance carrier shall review and
process the bill from the pharmacist in accordance with Chapter 133 and 134
(pertaining to General Medical Provisions and Benefits--Guidelines for Medical
Services, Charges, and Payment, respectively).
