Prepared To Meet Your Legal Needs

Workers’ comp in Pennsylvania: Are my meds covered?

On Behalf of | Jun 11, 2024 | Workers' Compensation |

In Pennsylvania workers’ compensation claims, in addition to compensation to help offset lost wages, injured workers are also eligible for reimbursement of medication costs. The Workers’ Compensation Act provides that employers bear the responsibility for prescription drug expenses.

What types of medications does workers’ comp cover?

Commonly covered medications can include:

  • Pain management: Analgesics (pain relievers) such as acetaminophen, NSAIDs (nonsteroidal anti-inflammatory drugs), and opioids as well as muscle relaxants for musculoskeletal injuries.
  • Anti-inflammatories: NSAIDs like ibuprofen or naproxen to reduce inflammation.
  • Antidepressants and anxiolytics: These may be prescribed for psychological distress resulting from workplace injuries.
  • Antibiotics: For infections related to the injury.
  • Topical medications: Creams, gels, or patches for localized pain relief.

Specific coverage may vary based on individual cases and medical necessity.

What are the rules for medication reimbursement?

There are two key terms used when discussing medication reimbursement for a workers’ comp claim.

  1. Average wholesale price (AWP): The Workers’ Compensation Act limits payment for prescription drugs and professional pharmaceutical services to 110% of the average wholesale price (AWP) of the product. This helps to better ensure reasonable compensation for medications.
  2. Red Book standard: Historically, the state Bureau of Workers’ Compensation relied on the “Red Book” standard for determining AWP. However, recent court decisions have set aside this standard.

As noted, the exact numbers used to calculate pharmaceutical costs is a matter of contention. Part of the court’s reasoning for setting aside the Red Book standard is the fact that it is set by a single manufacturer instead of an industry average. The court has called on the industry to put together a new, more accurate standard.

The issue serves as a reminder of the complicated nature of these cases. Those who are trying to navigate these matters are wise to stay current on the rules as they change to better ensure they get the compensation they deserve.