Prescription Limits in North Carolina Workers’ Comp Claims

In an effort to reduce workers’ compensation costs for state employees, North Carolina legislators examined the possibility of creating a drug formulary for the program. A drug formulary limits covered medicinal cost claims to a list of preferred prescription drugs. Both generic and brand-name prescriptions are often listed, with the sole goal of identifying medications that are effective at treating the condition in question while providing a good value.

Other states like Texas, Washington, California, Ohio and Oklahoma have already adopted drug formularies, somewhat indicating a bipartisan interest in the issue. North Carolina has such a program in place for Medicaid but investigating the issue concerning expansion to state workers’ compensation programs.

The ultimate goal of a drug formulary is to save the state and taxpayers money while reducing the chance of providing risky drugs, like habit-forming opioids. These goals are laudable, but a drug formulary could also have the effect of limiting options state workers need when filing workers’ compensation claims. In the future, they may need to consult with a North Carolina workers’ compensation attorney to fight for the right to file prescription claims for medications not found on the formulary list.

North Carolina’s Drug Formulary Study Findings

North Carolina’s General Assembly began their study process in November of 2015. The North Carolina Industrial Commission was the designated agency to conduct the study. Committee members included primary care physicians, pharmacists and certain medical specialists who regularly treat workers who were injured while on the job.

Study goals were fourfold:

• Assess the current state of annual pharmacy-related expenses for North Carolina workers’ compensation claims
• Examine the possibility of savings that could result from a drug formulary
• Consider potential efficiencies that would be gained from use of a drug formulary
• Outline an appeals process for health care providers and injured workers to seek approval for use of drugs not found on the formulary

An additional goal was to divert the use of risky drugs like narcotic painkillers in favor of less risk-prone ones when possible.

Results of the study concluded that a drug formulary would indeed reduce costs. Looking at claims from 2012 to 2014, researchers found that North Carolina could have saved between an estimated $1.4 million to $8.7 million if a drug formulary list had governed these claims.

Workers’ Comp Claim Prescriptions Under a Drug Formulary

North Carolina’s drug formulary for state workers’ compensation might be hypothetical for now, but the results of the study indicate that such a list could be implemented rather soon. A drug formulary could be a major win for taxpayers, but it could also limit the options of workers’ comp recipients in situations where an appeal to get the drugs they need would be difficult.

If you are being denied workers’ compensation claims or are concerned over how the proposed drug formulary could affect your access to prescriptions, contact a North Carolina workers’ compensation attorney today.
Call (704) 307-4350 for a free case evaluation.