Using Pharmacy Benefits Management to Control Narcotic Use in Workers Compensation

Since narcotics play an active role in the treatment of chronic non-malignant pain (including workers compensation injuries), it is essential for payors to take proactive measures in monitoring for opportunities or instances of misuse. An effective means to do this is to partner with a pharmacy benefits manager (PBM) experienced in the workers compensation industry. The remainder of this paper explores that role of the PBM. It also will provide insight on what to look for to ensure your organization reduces fiscal, legal and personal risk resulting from narcotics abuse.



The Role of a Pharmacy Benefits Manager (PBM)

Forming a partnership with a PBM can provide workers compensation payors a valuable resource in controlling narcotics use and thereby reducing risk for all stakeholders. There are eight key best practices PBMs can deploy to assist payors. We discuss the first four here.


Key Best Practices One through Four

(Key Best Practices 5 to 8 Discussed in Future Blog)


#1: Defining a Strategy

Getting control of narcotics usage requires a well-defined strategy. The first step in this process is for the PBM to review prescription history. Once the history is reviewed, it should be used to develop a customized narcotics strategy for each medication plan. These plans identify which medications are appropriate for the injury type and body part. They also account for proper duration of use and quantity limits. By defining a narcotics strategy, the workers compensation payor will have put into place the proper mechanisms to begin controlling narcotic use. (WCxKit)



#2: Capturing Prescriptions at First Fill

When new claims are filed, it is important to capture when and what type of medication is filled at the onset of injury. PBMs should have in place a mechanism to capture this prescription information. Often these early prescriptions begin telling the story of the medication history and medication therapy to come. One method to capturing this data is through First Fill cards. These cards are typically distributed by the employer to the injured worker at the point of accident or injury. To ensure both employers and injured workers use the program, PBMs should offer training programs on their use.



#3: Offering Home Delivery Programs and Retail Drug Cards

Both retail and home delivery programs provide the workers compensation payor an effective means to monitor and control an injured worker’s medication utilization. They also provide payors an opportunity to fully leverage pharmacy network participation and discounts, thereby reducing medication expenses.



Retail drug cards: When an injured worker requires additional medications, a retail drug card program will give the payor control over what, when and where the prescriptions can be filled. The injured worker should be able to use the retail drug card at the PBM’s retail network pharmacies. Not unlike a first fill prescription card, the retail drug card should contain injured worker-specific drug utilization review information to ensure only appropriate medications are filled.



Home delivery programs: A home delivery program offers the injured worker the convenience of ordering prescriptions either online or on the phone while providing the workers compensation payor the ability to engage in proactive utilization review programs. In addition, they also give the payor a mechanism to educate injured workers on the risks associated with narcotics through direct interaction with the pharmacist dispensing the injured worker’s prescriptions. Physician contact is often easier as well since the prescriptions are being managed directly through the mail order facility.



#4: Reduce Out-of-Network Bills

A high number of out-of-network bills can lead to issues with managing utilization of narcotics. Not only are individual out-of-network bills typically higher than those in-network, they are often not included in the utilization process. It is vital for payors to have a process in place for properly driving those bills back into the network. This can be done by working with a PBM offering both paper and electronic out-of-network bill solutions. This will ensure critical injured worker data on number of prescriptions, duration of therapy, doctor information and other related factors are captured to better monitor utilization.



However, the best method for controlling out-of-network bills is to make it easier for the injured worker to go in-network as early in the life of the claim as possible. One method for doing this is through First Fill cards, which are distributed by the employer at the onset of the injury. Two other strategies for reducing out-of-network bills are home delivery and retail drug card programs. (WCxKit)



It is expected narcotics will continue to play a role in treating pain in workers compensation. While greater oversight of narcotics use is already underway by the FDA through its REMS requirement, workers compensation payors must take proactive measures to reduce misuse and abuse. By doing so, payors decrease risk for litigation, improve injured worker safety and obtain more control over medication expenses.


Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: or 800.777.3574 or visit Progressive Medical.

About Progressive Medical
Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.


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