Getting meds or treatment denied after permanent medical is awarded

[BAKfusionL4-5/S1]

Jurisdiction

California

I have a permanent, lifetime, award for future medical coverage from my Work Comp settlement 10 years ago. My employer is Self insured so they administer the Work Comp program for all County employees. My Doctor prescribed a antidepressant drug in conjunction with other medications for the relief of severe pain. This is pretty standard treatment. I took the drug for many years and all of a sudden it is denied at the pharmacy.
I get no explanation from the county at all. Can they deny my doctors written prescriptions when it's a necessary part of my pain management plan? What is the recourse?

I have heard second hand rumors that other meds and even prescribed procedures are being suddenly denied with no explanation at all. Some drugs cause severe withdrawal if suddenly stopped and require rehab services to get off the meds. What can we do, we need pain relief to function and do normal daily activities. Or, god forbid, need medical support to go through immediate drug withdrawal. You get no advance warning just a denial at the pharmacy.

Is there any recourse once you've settled your claim? I appreciate any information you can provide me. Thank you for this opportunity!

 

[army judge]

I have a permanent, lifetime, award for future medical coverage from my Work Comp settlement 10 years ago. My employer is Self insured so they administer the Work Comp program for all County employees. My Doctor prescribed a antidepressant drug in conjunction with other medications for the relief of severe pain. This is pretty standard treatment. I took the drug for many years and all of a sudden it is denied at the pharmacy.
I get no explanation from the county at all. Can they deny my doctors written prescriptions when it's a necessary part of my pain management plan? What is the recourse?

I have heard second hand rumors that other meds and even prescribed procedures are being suddenly denied with no explanation at all. Some drugs cause severe withdrawal if suddenly stopped and require rehab services to get off the meds. What can we do, we need pain relief to function and do normal daily activities. Or, god forbid, need medical support to go through immediate drug withdrawal. You get no advance warning just a denial at the pharmacy.

Is there any recourse once you've settled your claim? I appreciate any information you can provide me. Thank you for this opportunity!

Read the fine print in your insurance contract, you agreed to take your disputes to arbitration or mediation.

There, you have your remedy.

Or, you can pay for your drugs out of pocket.

 

[ElleMD]

If this is WC, then the remedy is through the WC system. I deal with these kinds of questions daily. 95% of the time, there is a very easy fix and no nefarious intentions. Check that the pharmacy is contacting the proper insurer, has your information correct, and the Rx has been renewed by the doctor. Most of the time, that is where the problem lies.

If that checks out, look at your settlement. It may or may not have a sunset on certain treatments. If that checks, ask to see the medical record from the doctor's visit where it was prescribed. A decent number of "errors" come from the doctor indicating the Rx is for something other than a direct result of the WC claim. Insurance companies get those records and when the treatment is mentioned for something unrelated to the claim, it is denied.

If none of these fix it, call the adjuster. Ask why it was denied. Adjusters are human and make mistakes like anyone else.

If nothing else resolves it, you will need to file with the Division of WC. The issue will be set for hearing. in the meantime, pay for the Rx out of pocket and it will be reimbursed if you prevail at the hearing.