Document name
Medication Coverage
Document number
PRO 11/2019

Effective date: January 1, 2020

Approved date: November 19, 2019

Application: All medication purchases and approvals made on or after the effective date.

Policy subject: Allowance and expenses

Purpose:

Establish guidelines for covering medication costs.

BACKGROUND

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POL 11/2019, Medication Coverage outlines when the WCB will cover prescription and non-prescription medications required to effectively treat, or facilitate recovery from, an accepted work injury or disease. The following procedure outlines the steps followed for the approval and payment process.

PROCEDURE

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Medications – General

  1. Who authorizes coverage of prescription or non-prescription medications?
    1. A Case Manager (CM), Case Manager Support (CMS) or Claims Entitlement Specialist (CES) will authorize the coverage and payment of prescription and non-prescription medications prescribed or authorized by the worker’s health care provider.
    2. If it is not clear that the medication is required or appropriate to treat the work injury, staff will refer the claim to a WCB Medical Officer (MO) for review and approval.
      1. This includes, but is not limited to, the following situations:
        1. A new prescription not in The Saskatchewan Formulary.
        2. An alternative health product.
        3. A pharmaceutical cannabinoid product or medical cannabis, or
        4. The medication is approved for off-label use by a WCB MO (i.e., the use of a medication beyond what is indicated on the product label).
    3. The CM, CMS, or CES will communicate all medication coverage decisions to the worker.
  2. When are non-prescription medications covered?
    1. Operations staff will authorize payment for over-the-counter (OTC) medications if recommended by the health care provider to treat a work injury or as an alternative to prescription medications.
      1. Examples include, but are not limited to, analgesics (e.g., Tylenol, Advil, etc.) and topical ointments (e.g., polysporin for burns or hydrocortisone (half per cent) for dermatitis, etc.).
    2. Operations staff will authorize payment for alternative health products if recommended by the treating health care provider.
      1. Examples include, but are not limited to, vitamins, nutritional supplements, or herbal remedies that are recommended to improve the worker’s quality of life, which may have been compromised by the work injury.
      2. For example, supplementary vitamins may be recommended to improve the energy and well-being of customers with some types of cancer.
  3. Operations staff may request that a WCB MO review the health care provider’s recommendation for an OTC medication or alternative health product if:
    1. It is not clear that the product is required or appropriate to treat the work injury, or
    2. The dosage or quantity appears excessive.

Medications – Payment

  1. Will costs for medications be reimbursed if a worker has already paid for a medication(s)?
    1. If a medication has been authorized for coverage, a worker must submit copies of the receipts to the WCB for medications they have already paid for.
    2. The worker must retain original receipts for 12 months from the date of submission as the WCB may request the originals for audit purposes.
  2. Can a pharmacy direct bill the WCB?
    1. A CMS or CES may authorize a pharmacy to direct bill the WCB. They will notify the pharmacy what medications will be covered and document all medications authorized to be direct billed on the claim.
    2. A Medical Payment Specialist will complete payment directly to a pharmacy based on a review of the authorization provided by the CMS/CES on the claim.
  3. What if a medication is not approved?
    1. The CMS/CES will notify the injured worker directly if they determine a medication is not related to the treatment of a work injury, and therefore not eligible for coverage.
    2. If a medication is not approved and payment to a pharmacy is made in error, the CMS/CES will request a Medical Payment Specialist to cancel the payment and notify the pharmacy of the cancelled payment.
    3. If coverage for a medication is denied following a WCB MO’s review, the CMS/CES will provide the injured worker and the treating health care provider written reasons for the decision.
    4. A WCB MO may reconsider a decision to deny coverage of a medication if the worker’s health care provider provides additional information or explanation to accept coverage of the medication.

Opioid Treatment Management

  1. If an opioid is prescribed (i.e., for pain related conditions such as, but not limited to pre-operation situations, palliative care, chronic bowel conditions, opioid addiction treatment with methadone or suboxone, etc.), is there a limit to coverage?
    1. If the WCB is providing payment for an opioid, treatment will be monitored to ensure the opioid continues to be effective in improving function and reducing pain.
    2. Opioid treatment will be monitored as follows:
      1. The CES/CM will document on the claim the date opioids were first prescribed and the name of the prescribing health care provider.
      2. Opioid use 6 weeks past the date of injury or post-surgery will require a Case Management review and may require a referral for a multidisciplinary assessment by a pain management specialist and psychologist.
      3. Operations staff may request a WCB MO review.

Pharmaceutical Cannabinoids and Medical Cannabis

  1. The WCB may approve, on a case by case basis, the use of pharmaceutical cannabinoids or medical cannabis when requirements noted in POL 11/2019, Medication Coverage are met.
  2. In what situations could the cost of a pharmaceutical cannabinoid product or medical cannabis be covered?
    1. The injured worker has a listed condition noted in POL 11/2019, Medication Coverage and the condition is clinically associated with a work-related injury or disease or its treatment.
    2. The worker’s treating health care provider has prescribed pharmaceutical cannabinoids or authorized medical cannabis to treat the condition.
    3. Other lines of treatment have been tried and were not successful in treating the worker’s condition or illness.
    4. In the opinion of the WCB MO, the pharmaceutical cannabinoid or medical cannabis prescribed or authorized by the treating health care provider:
      1. Meets currently published guidelines for safe and effective use.
      2. Will benefit the injured worker’s medical condition related to the work injury or will facilitate their recovery, and
      3. Meets appropriate dosage and route of administration, and
      4. It is recommended by a WCB MO for cost reimbursement.
  3. The CES/CMS will confirm the following information:
    1. The worker has a listed condition, which is clinically associated with a work injury or disease or its treatment.
    2. The health care provider who has prescribed or authorized the product is the care provider responsible for managing the ongoing care of the worker including assessing the worker’s response to the treatment.
    3. A copy of the health care provider’s prescription (for pharmaceutical cannabinoid), written order or medical document (for medical cannabis) is obtained.
    4. If medical cannabis was authorized by the worker’s health care provider:
      1. The cannabis authorized must be oil drops for oral administration.
      2. The written order must include detailed information regarding authorized daily allowance, equivalency factor, dosing guidelines, and active ingredients (i.e., percentage of tetrahydrocannabinol (THC) and cannabidiol (CBD)), and
      3. It will be confirmed the product was obtained, or will be obtained, from a licensed producer/seller and the product matches the treating health care provider’s recommended per cent of active ingredients, dosage and route of administration.
  4. Once this information is confirmed, the CES/CMS must refer the claim to a WCB MO for review and recommendations prior to approving coverage.
  5. What information does a WCB MO consider during their review?
    1. The WCB MO will confirm that the treating health care provider’s recommendation is based on current medical research and any published guidelines from medical associations.
    2. The WCB MO will confirm that:
      1. The health care provider has tried other lines of conventional treatment, which were found to be ineffective or not tolerated.
      2. Pharmaceutical cannabinoids or medical cannabis is an appropriate treatment for the worker’s injury (i.e., will lessen the injured worker’s medical condition related to the work injury or will facilitate their recovery).
      3. The recommended product is considered safe and effective, and
      4. The recommended dosage and the per cent of active ingredients in the authorized product are appropriate (e.g., THC and CBD).
  6. Once the information has been reviewed, the WCB MO will determine if use of a pharmaceutical cannabinoid product or medical cannabis is appropriate and will provide their medical opinion to the CM/CMS/CES.
  7. The CM/CMS/CES will notify the worker if coverage for the pharmaceutical cannabinoid product or medical cannabis has been approved.
  8. When medical cannabis is recommended and approved, what information is considered before costs are covered?
    1. Only cannabis oil drops for oral administration may be covered.
    2. A copy of the licensed producer/seller’s itemized invoice must be provided (i.e., must include a description and the quantity of the product).
    3. WCB staff will review the invoice to ensure the products are in alignment with the health care provider’s medical document or written order:
      1. Coverage will not be approved where the product does not align with the care provider’s recommendation.
      2. To be covered, the product amount on the invoice must align with the amount specified in the health care provider’s dosing instructions or authorized quantity.
        1. For example, specific millilitres (ml) of oil multiplied by 30 days should equal invoiced product amount.
      3. WCB staff may restrict coverage to a preapproved limited supply (e.g., one month) to ensure alignment with the health care provider’s written order.
    4. Costs of the authorized and approved product, any associated shipping costs, and taxes invoiced by the licensed producer/seller will be covered.
  9. If a request for coverage of a pharmaceutical cannabinoid product or medical cannabis is received for a condition or illness not listed in POL 11/2019, Medication Coverage, a WCB MO and the Chief Medical Officer will provide recommendations on coverage based on current medical research and guidelines. The Chief Medical Officer will determine if updates to the policy are required.
  10. WCB staff will advise workers to:
    1. Discuss possible work and driving restrictions with their treating care provider, and
    2. Ensure they are aware of their employer’s policy on impairment in the workplace.

Overuse or Abuse

  1. Who monitors for overuse and abuse of medications?
    1. The CMS/CES will monitor what medications the WCB is reimbursing and possible overuse/abuse or interactions. This includes overuse/abuse of a controlled drug (i.e., opioids) or identifying if several medications or a single medication is being used in large quantities.
    2. The CMS/CES may consult with a WCB MO before making this determination.
  2. What happens if overuse or abuse is suspected?
    1. The CMS/CES will refer the claim to a WCB MO who may:
      1. Request that the treating health care provider limit the use of the drug.
      2. Recommend authorizing payment for a restricted or limited amount, or
      3. Recommend that payment authorization be denied.
  3. What services are covered if a worker develops an addiction to a prescribed or authorized medication?
    1. In some situations, even when used appropriately, medications can lead to addiction.
    2. If medical evidence supports that the addiction is the result of treatment of an accepted work injury, the cost of a medication dependency treatment program or strategy will be covered.

Policy references

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Legislative Authority

Section detail

The Workers’ Compensation Act, 2013
Sections 2(1)(v), 19(1)(b), 20, 25, 31(1), 55, 103, 104, 109, 111, 115(c)
 

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References

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Document History

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(1) POL and PRO 10/2011, Reimbursement for Medications (effective October 1, 2011 to December 31, 2019).
(2) November 1, 2017. Requirement for original receipts updated to copies of original receipts; however, original receipts must be retained for 12 months from submission date, as they may be requested by the WCB for audit purposes.
(3) POL and PRO 10/2011 reviewed November 2, 2012 and no updates recommended.
(4) POL and PRO 09/2001, Reimbursement for Medications (effective November 1, 2001 to September 30, 2011)
 

Section heading

Complements

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