WCB Procedures

Pharmacy direct billing and medication management

Procedure summary

Published On

Feb 20, 2024

Purpose

To manage Alberta Blue Cross (ABC) Pharmacy Direct Billing service, reimburse a worker for medication expenses when they pay out of pocket, and manage emergency medication authorizations.

Description

Injured workers are automatically enrolled to the ABC Pharmacy Direct Billing service by the eCO system when certain criteria are met and do not have to actively enroll for the service. Workers may also choose to unenroll themselves from the service. Additionally, WCB Alberta may choose to unenroll a worker from the service if there is evidence of misuse of the service, or in select cases where a worker is participating in an opioid tapering program and issues arise.

When a worker has paid out of pocket for medications related to their compensable injury, the decision maker processes reimbursement for the medication expense.

Emergency situations that involve a worker being exposed to blood or bodily fluids (i.e., bite, cut, scratch, puncture wound or needlestick injury etc.), require urgent authorization for prophylactic medication prior to the claim being registered or accepted. The approval for this type of medication is usually completed by a customer contact center representative who receives a call from the pharmacy, worker or the employer.

Key information

Alberta Blue Cross (ABC) Pharmacy Direct Billing service

The Alberta Blue Cross (ABC) Pharmacy Direct Billing service allows pharmacies to direct bill eligible prescription drug medications based on a set of approved medication packages.

All eligible claims will be automatically enrolled in the ABC Pharmacy Direct Billing service, along with the appropriate standard injury and/or manual medication package(s).

Claim eligibility criteria to be enrolled include:

The claim's Entitlement decision is "Accepted" and has an Open Claim status
The claim is time loss (TL) or no time loss (NTL)
The claim has at least one accepted nature of injury (NOI) with "Current", “Recurrent” or "Ongoing" status and that NOI is eligible for injury packages
The worker does not have a date of death, and
The worker has not been manually unenrolled (does not have a Pharmacy Billing Exclusion Reason).

An auto-enrollment letter is automatically sent to the worker once a claim has been enrolled in the service.

Note: Enrollment and unenrollment in the pharmacy direct billing service does not constitute an entitlement decision.

Whether a worker is enrolled in the service, is manually unenrolled by WCB, or chooses to be unenrolled, they continue to be eligible for reimbursement of eligible prescription drug medications by alternate methods:

Paying for their claim-related medications themselves and submitting the receipt for reimbursement from WCB, or
By having the pharmacy fax invoices to WCB for reimbursement.

See the ABC Pharmacy Direct Billing page on the internal WCB Made Easy site for more information.

Medication Reimbursement

When a worker pays for out of pocket for a medication, the decision maker determines if the medication was prescribed for the compensable (accepted) injury and if so, reimburses the worker for the cost.

Bodily fluid exposure requiring urgent medication

Certain medication may require emergency authorization through the customer contact center (CCC) before a claim is registered or accepted such as prophylactics when a worker has been exposed to blood or bodily fluids.

Pharmacy direct billing

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Approve additional medications for direct billing

There is no enrollment required for a worker in the ABC pharmacy direct billing service as it will be automatically done based on the criteria outlined in the key information section.

When a worker requires a medication that is not part of the standard or injury medication package(s), determine if the medication relates to the compensable injury. When the medication is prescribed for the injury, add the additional approved medications to the authorized medications line. Medications that are submitted that are not approved are also added to the authorized medication line with the status of denied so the claims contact center, or any other WCB staff member does not approve them in the future.

Note: Adding medications to the system will trigger enrollment in an associated medication package, which will then permit direct billing at the pharmacy level for that medication.

Follow the 4-1 Medical testing, referrals and program support procedure to refer the claim to the medical consultant for an opinion if assistance is needed to determine if a medication is required for the compensable injury or if ongoing responsibility for prescriptions should be approved.

Opioid tapering and medication management programs

Workers are normally entitled to maintain enrollment in the pharmacy direct billing service while participating in a medication management or opioid tapering program.

In addition to medications listed in their standard and injury medication packages, they may require additional medication(s) to manage symptoms of withdrawal while participating in a medication management or opioid tapering program. These medications are not normally part of a direct billing medication package.

The pharmacist will first try to bill a claim-related prescription through pharmacy direct billing. If the medication is rejected by the direct billing system but should be covered as part of the medication management or opioid tapering program, the pharmacist will fill the prescription as authorized by the WCB.

Administrative tasks

Enter approved medications in the Benefit Details tab of the Authorized Medication (AUM) line (including medication not included in a standard or injury medication packages); ensure the start and end dates are updated.

To indicate whether any prescriptions should not be approved by the Claims Contact Centre, add a file note (Medications & Dressings / Details); include the standard text CM/adjudicator Authorizations Only in the Description field and a claim alert stating the same.

To approve opioid (narcotic) prescriptions, add a file note (Medical Payment Processing) and attach it to the AUM line.

Note: All generic Oxycodone/Oxycontin formulations are not payable as of April 11, 2013. To determine if the narcotic/opioid medication is generic, and/or not payable, go to the internal Opioid Claim Management (EW site>More Resources>Special Drugs>Narcotic List and MEQ Calculator: Tab>Class A Opioids excel spreadsheet and compare the prescription DIN to the listing of those narcotics that are shaded brown).

See the 4-7 Opioid management procedure for more details.

Unenroll a worker from the direct billing program

Administrative tasks

Document the discussion in a file note (Contact/Claimant Contact) and attach it to the Authorized Medication line.

Complete the Medical Consultant Referral (FM007A) form.

Send a file note (Medical/Details) to the Address Book Librarian asking that they remove the worker from the service and attach it to the Authorized Medication line.

Send the Unenroll ABC Pharmacy Direct Billing (CL400A) letter to the worker and their representative, if applicable. Do not notify the employer or the employer representative.

Reimbursement for workers who purchase medication

Process reimbursements for medications not enrolled in direct billing

Review the request for reimbursement for completeness. This means ensuring that submissions include the worker’s name, claim number and eligible proof of payment (copies of original receipts are acceptable; bank statements are not).

In those instances where a prescription medication cannot be direct billed through Alberta Blue Cross, receipts must be submitted, but originals are not required. Workers can submit the receipt via the Worker App or by mail, fax, or email of scanned or photographed original receipts.

Administrative tasks

When payable, request the payment on the eCO Payment Request screen.

Once requested, the:

The medication will be attached to the Authorized Medication line, if not already attached,
The Benefit Details tab will be updated,
A cheque or direct deposit will be sent to the payee/bank or a benefit approval exception will be sent to the decision maker.

Emergency medications approved by the Claims Contact Centre

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Emergency medication approval for bodily fluid exposure

A worker, pharmacy or employer may initiate a call when there has been exposure to blood or bodily fluid (i.e., bite, cut, scratch, puncture wound or needlestick injury etc.) at work. In these cases, emergency prophylactic medication may be required before the claim is registered and/or accepted.

First, the customer contact center representative (CCR) will review to determine if a claim has already been established. If a claim is already established but no decision has been made proceed to “if employer is covered under the act” section below.

If a claim has not been established, and emergency authorization is needed for prophylactic medication, the following information is obtained through completing the C060M. The worker or pharmacy calling may not be able to provide all of this information but the more we can get the better to establish a claim:

Worker's full name
Address
Phone number
Date of birth
Personal Health Care Number
Social Insurance Number
Date of Accident
Injury
Name of employer/contact name
Description of Accident

Once this information is gathered the CCR will phone WCB employer account services to help determine if the employer is covered under the Act. If it is clear that the employer is covered (e.g., City of Edmonton, Canada Post, Alberta Health Services etc.,) a phone call is not required.

If the employer is covered under the Act gather the following information from the caller seeking prophylactic medication:

pharmacy name
contact person and phone number
name of medication
DIN
physician's name
approximate cost for a 7-day supply of medication

A priority claim can now be registered and the caller should be informed that they will be called back within two hours with a claim number.

Once a claim is established the CCR's can approve a 7-day supply of prophylactic medication in case a decision maker is not assigned or available in that time period. The typical cost of this medication is $200-$500 but may vary.

The pharmacy may request approval in writing as opposed to over the phone.

If the employer is not covered under the Act:

Advise the caller that the prescription cannot be authorized at this time.
Complete C060M and send to registry and advise they will receive a claim number within 2 hours.
Direct the worker to follow up with their treating doctor and/or public health center. The worker should also be advised to tell their employer about the incident if they haven't done so already.

In the case of bodily fluid exposure, the claim will be managed by the assigned decision maker or it will be assigned to a decision maker in Special Care Services to make an entitlement decision, once the claim threshold is exceeded. There are unique nature of injury (NOI) and source of injury (SOI) codes for these types of claims.

Once the claim has been established, it will be assigned to a decision maker to determine entitlement. Follow procedure 1-1 initial entitlement decision.

Administrative tasks

Complete the C060M form with the caller (e.g. worker or pharmacy) and right-fax (as indicated on the form) or email the Registration Priority team at mailbox.registryemails@wcb.ab.ca to establish a claim. CCC must check for confirmation the email was successfully sent to ensure timeliness.

If a claim has already been established then Document approval in a file note (Phone Call-No C/B required, Product Supplier).

If the pharmacy requires authorization in writing send SP028A emergency authorization letter to the pharmacy and email a copy to registry.

SOI (source of injury) is bodily fluid exposure, code 57100

If there is an injury sustained (bite, cut, scratch, puncture etc.,) with exposure to bodily fluid, use the grouping “physical injury”, and the codes:

03700: puncture except bites (typically for needle sticks)

04100: scratch/abrasion

03000: open wound

If no injury was sustained but contact with bodily fluid occurs (e.g., splash to face, spit in mouth/eyes) use grouping of “occupational illness” 50000.

Additional medications approved by the Claims Contact Centre representative

If the claim is not part of the pharmacy direct billing service, the Claims Contact Centre (CCC) can approve various prescriptions.

Analgesic, muscle relaxant, NSAIDsNon-steroidal anti-inflammatory drugs or anti-inflammatory

The Claims Contact Centre can approve these types of medications when:

The WCB-approved injury is a soft tissue injury or an injury to bone or cartilage.
The medication is being dispensed is intended to last four weeks or less. If it is greater than four weeks, it will be sent to the claim owner for review. Exception: “Miscellaneous Anxiolytics Sedatives” and “Anxiolytics Sedatives and Hypnotics”, prescriptions lasting longer than two weeks should be deferred to the claim owner for a decision. If the length of the prescriptions is two weeks or less, a CCR can communicate the approval.
For NSAID medication, the claim must be active, have a status of "accepted", “processed” or “medical investigation” and not have any prescription restrictions that should only be authorized by a decision maker in the Additional Program Information field of the Authorized Medication (AUM) line.
It is apparent that, at the time of the prescription the disability was accepted by a claim owner as a WCB-approved injury. To determine if this is the case, one of the following criteria must apply:
- There is an updated Authorized Medication line - Benefit Details tab, in which payment of an analgesic, muscle relaxant or anti-inflammatory medication has been authorized. Note: The exact type of medication does not need to be authorized provided it can be reasonably related to the compensable injury. If the decision maker has approved payment of an analgesic the Claims Contact Centre can authorize payment of an anti-inflammatory or muscle relaxant medication.
It is assumed the need for the prescription is related to the WCB approved injury. Indicators for that include:
- The worker is in receipt of a temporary total or partial disability benefits (TD01 or TD02), wage loss supplement (TEL, TPD or ELP), vocational rehabilitation (VR01, VR02, VR04 or VR05) or personal care allowance payment at the time of the prescription.
- The worker was awarded a Permanent Partial Disability or Non-Economic Loss payment for a soft tissue injury or an injury to bone or cartilage.
- There is an updated letter and/or the Injury Details screen supports there is ongoing WCB approval for the worker's disability.
- The claim has been accepted by a decision maker or processed by the Process Desk.

Antibiotics

The Claims Contact Centre can approve antibiotic medication when:

The medication is being dispensed within eight weeks of the date of accident, date of sub-layoff or date of surgery for:
- WCB-approved laceration, open wound or burn injuries if the date of the prescription is within eight weeks of the date of accident.
- WCB-approved post-surgery recovery.

Administrative tasks

Document the approval in a file note (Phn call-no c/b required, Product Supplier).

Note: CCC should not be approving medications beyond the date of the request. If authorization is requested in writing this is up to the Claim owner and the CCC representative will engage them through normal practices (i.e., phone call or file note).

Claim owner will then update authorized medications line within 5 days and adjust the approved date range.

See the internal CCC Procedure: Medication Authorizations by a CCR for further information (EW>Departments>Claims Contact Centre>CCR Guidelines>Medication Authorization by a CCR).

Supporting references

Policies

Policy 04-06, Part II, Application1- General

Procedures

4-7 Opioid management
20.6- Investigations Unit Referral

Workers’ Compensation Act

Applicable sections

Section 83 (1)- Agreements Respecting Medical Aid
Section 86- No Charge for Medical Aid

General Regulation

Applicable sections

Related Legislation

Applicable sections