(a) If an injured employee needs to purchase prescription
drugs or over-the-counter alternatives to prescription drugs prescribed
or ordered by the treating doctor or referral health care provider,
the injured employee may request reimbursement from the insurance
carrier as follows:
(1) The injured employee must submit to the insurance
carrier a letter requesting reimbursement along with a receipt indicating
the amount paid and documentation concerning the prescription.
(A) The letter should include information to clearly
identify the claimant such as the claimant's name, address, date of
injury, and Social Security number.
(B) Documentation for prescription drugs submitted
with the letter from the employee must include the prescribing health
care provider's name, the date the prescription was filled, the name
of the drug, employee's name, and dollar amount paid by the employee.
As examples, this information may be on an information sheet provided
by the pharmacy, or the employee can ask the pharmacist for a printout
of work-related prescriptions for a particular time period. Cash register
receipts alone are not acceptable.
(2) The insurance carrier must pay the injured employee
under §134.503 of this title (Pharmacy Fee Guideline), or notify
the injured employee of a reduction or denial of the payment within
45 days of receiving the request for reimbursement from the injured
employee.
(A) If the insurance carrier does not reimburse the
full amount requested or denies payment, the insurance carrier must
include a full and complete explanation of the reasons the insurance
carrier reduced or denied the payment and must inform the injured
employee of his or her right to request medical dispute resolution
under §133.305 of this title (MDR--General).
(B) The statement must include sufficient claim-specific
substantive information to enable the employee to understand the insurance
carrier's position or action on the claim. A general statement that
simply states the insurance carrier's position with a phrase such
as, "not entitled to reimbursement" or a similar phrase with no further
description of the factual basis does not satisfy the requirements
of this section.
(b) An injured employee may choose to receive a brand-name
drug rather than a generic drug or over-the-counter alternative to
a prescription medication that is prescribed by a health care provider.
In such instances, the injured employee must pay the difference in
cost between the generic drug and the brand-name drug. The transaction
between the employee and the pharmacist is considered final and is
not subject to medical dispute resolution by the division. In addition,
the employee is not entitled to reimbursement from the insurance carrier
for the difference in cost between generic and brand-name drugs.
(1) The injured employee must notify the pharmacist
of their choice to pay the cost difference between the generic and
brand-name drugs. An employee's payment of the cost difference is
an acceptance of the responsibility for the cost difference and an
agreement not to seek reimbursement from the insurance carrier for
the cost difference.
(2) The pharmacist must:
(A) determine the costs of both the brand-name and
generic drugs under §134.503 of this title, and notify the injured
employee of the cost difference amount;
(B) collect the cost difference amount from the injured
employee in a form and manner that is acceptable to both parties;
(C) submit a bill to the insurance carrier for the
generic drug that was prescribed by the doctor; and
(D) not bill the injured employee for the cost of the
generic drug if the insurance carrier reduces or denies the bill.
(3) The insurance carrier must review and process the
bill from the pharmacist under Chapters 133 and 134 (General Medical
Provisions and Benefits--Guidelines for Medical Services, Charges,
and Payments, respectively).
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Source Note: The provisions of this §134.504 adopted to be effective January 3, 2002, 26 TexReg 10970; amended to be effective March 14, 2004, 29 TexReg 2346; amended to be effective October 23, 2011, 36 TexReg 6949; amended to be effective November 28, 2024, 49 TexReg 9758 |