How to Help the Claims Adjuster Think like a Pharmacist

When it comes to workers’ compensation pharmacy claims it could be helpful to have your own personal experienced pharmacist sitting by your side, evaluating claims and determining appropriateness of the drug regimen compared to the compensable injury. Rather than providing pharmacists to all of our customers we are offering a few tips in an attempt to guide you through the maze of medication utilization so that you can apply some seasoned pharmacist skills to your injured workers’ pharmacy profiles.

Multiple pharmacy locations

  • Filling scripts at different pharmacy locations prevents a single pharmacist from reading the whole health picture of the injured worker and precludes the clinical oversight of duplications, drug interactions and other complications
  • If the injured worker is using multiple pharmacies you have the opportunity to suggest either getting all medications through a single local pharmacy or moving maintenance medications to a mail order program to ensure the safety of the injured worker by having one pharmacist see all of the potential adverse interactions in one place

Early refills

  • Industry standards allow refills of prescriptions a few days before the injured worker runs out of medication so that there will not be any interruption in treatment
  • If an injured worker is consistently getting strong medications (opioids, benzodiazepines, muscle relaxants etc.) a few days early every month then this may be an indication of a larger problem such as sub-therapeutic treatment or a slippery slope to misuse, abuse or addiction
  • If you find an injured worker has been getting early refills of strong medications consistently then you could reach out and talk about the reasons for this trend and the your concerns about the injured worker’s safety

Non-compliance or skipping doses

  • This may seem like a great way to save money but if an injured worker is not taking medications regularly as directed by the physician then the next office visit may include the injured worker being elevated to a stronger, often more expensive treatment option if the current medications are not providing relief
  • If this is something you are aware of, you could reach out and inquire about the treatment regimen and whether there are issues with calling in refills, taking the medications at the correct time, lack of efficacy or side effects which prevent the use of the medication
  • With the correct information the prescriber can make the proper dose adjustments or medication choices or even utilize mail order to improve adherence to a therapeutically appropriate plan

By: Sean D. Chitwood, PharmD, MBA