Why Can't I Choose My Pharmacy Under Workers' Comp?

Posted by Danielle Jaffee on Sep 28, 2017 8:00:00 AM

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Workers' compensation is not like traditional health care, and your coverage isn’t like your normal health insurance coverage.  The reason? Because under workers’ compensation your employer is paying for your treatment. For the most part, you aren’t expected to put out any money when receiving workers’ comp benefits. 

Because of this, the rules of treatment get a little tricky.  The biggest thing most injured workers notice after they’ve been injured on the job is that the employer has more control over medical treatment than they would have had the injury not occurred at work.  This varies by state, but under some laws the employer has the right to select your treating physician and/or the pharmacy you go to for your prescription medications.  This practice is called direction of care.

The states that allow direction of care, either for your physician or your pharmacy, argue that because employers are paying for the benefits they have a right to pick the medical providers treating you.  This allows them to create networks, establish contracts, and negotiate pricing - they get to control their costs, while you still receive medical treatment for your injuries. 

Often where you find direction of care for physicians, employers can also direct care for the pharmacy.  But that’s not always the case, for example in Pennsylvania, the employer is allowed to direct an injured worker to designated providers, but the patient has choice of pharmacy. 

Other states, however, have gone the opposite way.  Florida, Maine, New Hampshire, and Texas all have laws that allow the injured worker to choose their pharmacy - they protect patient choice.  Some states remain silent on the issue, not specifically saying who can choose the pharmacy, in those states patient choice should be honored.  Those states include Colorado, Oklahoma, and Wisconsin. 

So what does this all mean for the injured worker? Well, like many things in workers’ comp, it depends on what state you’re in, but just because your employer is paying doesn’t mean they get to control everything.  The rules and case law that dictate these types of questions are constantly changing and direction of care and patient choice remain a hot issue in workers’ comp across the country.

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Topics: Legislative, Workers' Compensation