As Americans, we value our independence. As advocates for injured workers, we also value independence. We know that injured workers will only receive the medical treatment they need from doctors who are not affiliated with the Insurance Company. We also know that we can’t trust the vocational expert hired by the Insurance Company to render a fair and impartial earning capacity evaluation. Ensuring that your clients’ pharmacy is independent of the Insurance Carrier is just as important.
Insurance Carriers pressure your clients to use a pharmacy of their choice for two reasons. The first is that the Insurance Carrier claims that they receive a discount by using a Pharmacy Benefits Manager (PBM). However, this discount is usually very minimal considering the PBM also needs to make a profit on the medications. The second and more important reason is that the Insurance Carrier is able to control your clients’ treatment. Insurance Companies, PBMs and pharmacies rely on an electronic switch to communicate regarding what medications are approved and what reimbursement price will be paid. An adjuster can mark a file stating a medication is denied and then most pharmacies nationwide will refuse to fill the medication. The medication may be clearly related to the accepted injury and even have been found reasonable and necessary in utilization review proceedings. The denial is not based on facts or the law but rather on the Insurance Carrier’s bottom line. The hope is that if a medication is denied, the injured worker will take the path of least resistance and do without the expensive medication or switch to a medication the Insurance Carrier finds more palatable. This results in decisions regarding your client’s medical treatment being made by the Carrier instead of the treating physician.
So during this 4th of July holiday, when we reflect on what independence means to us as Americans, we humbly, humbly ask that you also reflect on what having an independent patient advocate pharmacy means to your clients.
Have a happy and healthy 4th of July!