Refusal to pay prescription costs after issuing plan card warrants penalty

Where an employer supplies a worker with a prescription card to obtain medication for his work-related injury, it cannot insist that the worker submit the bills on the proper forms as a prerequisite for payment.

Case name: Zwickle v. Port Authority of Allegheny County, 24 PAWCLR 101 (Pa. W.C.A.B. 2009).

Ruling: The Pennsylvania Workers' Compensation Appeal Board affirmed the award of penalties against the employer.

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What it means: Where an employer supplies a worker with a prescription card to obtain medication for his work-related injury, it cannot insist that the worker submit the bills on the proper forms as a prerequisite for payment. A penalty is warranted if the employer fails to make payment when the worker has complied with the agreed-upon streamlined procedure.

Summary: The board found that the employer's failure to provide timely payments for prescriptions under a system it implemented was a basis for penalties. The worker alleged that the employer violated the workers' compensation act by failing and refusing to pay his reasonable and necessary prescription expenses. The employer issued the worker a prescription card to purchase medication for his work-related injury. When he presented the card at a pharmacy, payment was denied, requiring the claimant to use his health insurance and make a co-payment. The worker paid $4,355.64 in prescription expenses and $562.70 in out-of-pocket expenses. A workers' compensation judge ordered the employer to pay the worker's out-of-pocket expenses and a $281.35 penalty. The board affirmed, rejecting the employer's argument that the WCJ erred by finding a violation of the WCA because it had no notice that the claimant's prescriptions were denied and his physicians failed to submit supporting documentation.

The board found that by enacting this procedure, the employer waived strict compliance with the law and was liable for nonpayment of work-related prescription costs due to rejection of the prescription card.

The employer's workers' compensation supervisor testified that the prescription card provided a toll-free number for the pharmacist to contact the prescription plan administrator if payment was not authorized by computer. The prescription could then be approved immediately and the expense billed to the employer. However, the board agreed with the WCJ that the pharmacist did not have a duty to call a toll-free number.

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July 20, 2009

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