Are all prescribed drugs covered by workers' comp benefits?
While there are exceptions and lengthy processes for some approvals, New York workers' compensation benefits will generally pay for all necessary medical procedures and drug prescriptions related to work injuries and illnesses.
This sounds straightforward. If your doctor says you need it for your health, it's necessary and should be covered, right? Unfortunately, that's not what always happens. Insurance companies will use any excuse to deny or reduce a claim. Workers' compensation insurance providers frequently have a very different opinion from medical professionals about what is "necessary" for a worker to recover.
When workers' compensation refuses to cover an important medication, injured employees need to know their options. An experienced workers' compensation attorney can help. The legal team at Pasternack Tilker Ziegler Walsh Stanton & Romano LLP has been fighting to protect the rights of injured New York workers for more than 80 years. We know how the system works and how to make it work for people who were injured on the job.
Will NY workers' comp cover ALL prescription drugs?
Yes, but there are exceptions and challenges to recovering medication expenses. Once a claim is accepted, workers' comp is obligated to pay for all necessary medical treatments, including prescribed medications. However, not all medications are treated the same by workers' comp. Some prescriptions require a lengthy pre-approval process, after which, if you win, workers' comp will pay for them. At the same time, others are covered without question.
As we noted earlier, the challenge arises when insurance companies dispute the necessity of certain medications or medical treatments recommended by healthcare professionals.
Which prescription drugs are covered by workers' compensation?
New York has an official list that specifies the drugs covered for various work injuries and illnesses. The workers' compensation "drug formulary" includes coverage guidelines for employee injuries such as ankle/foot injuries, back problems, elbow injuries, eye conditions, hand/wrist/forearm injuries, hip/groin injuries, lung diseases, knee injuries, neck injuries, shoulder injuries, and traumatic brain injuries (TBIs), among others. If a doctor-prescribed drug is not listed in the formulary, the injured worker has to apply for pre-approval. In New York, pre-approval may involve three levels of review.
What is the process for prescription drug pre-approval in New York?
To get prior authorization from the insurance company for medication, a worker needs to take action right away. Their doctor or medical provider must submit a Prior Authorization Request (PAR) to the state's "OnBoard" system, provide documentation, and pass up to three levels of review. If pre-approval is denied, the decision can be appealed.
An attorney can advocate for the benefits you deserve
At Pasternack Tilker Ziegler Walsh Stanton & Romano LLP, our attorneys are dedicated to protecting the legal rights of injured workers in New York. From investigating the accident and collecting evidence to handling insurance matters and aggressively negotiating for maximum compensation, we are committed to advocating for your rights. If you were injured at work in New York, contact us for a free case evaluation.