Workers’ compensation is an insurance policy that provides medical care and/or cash benefits to workers who fall ill or get injured while working their jobs. Employers and business owners pay for this insurance and are required, by law, not to pass this cost to their employees. The medical care and cash benefits are sorted and paid for by the company’s insurance carrier at the direction of the Worker's Compensation Board.
This board processes workers’ compensation claims and determines whether they will receive cash settlements, medical care, or both. They also determine how much the insurance carrier should pay the affected worker.
In most of these cases, no party is declared to be at fault, so the settlement amount is not determined by the worker or employer’s perceived negligence. However, an injured worker’s claim may be denied if it is proven that their injury resulted from the influence of alcohol or drugs. It can also be denied if they intentionally hurt themselves or another worker.
Companies, through their insurance carriers, honor worker compensation claims if they successfully determine and agree that the illness or injury occurred because of their work. Otherwise, they reserve the right to dispute the claim and delay any payment until a judge rules in favor of the worker.
Insurance carriers work with Pharmacy Benefit Managers (PBMs) like myMatrixx to make sure that ill or injured workers receive the appropriate medication at the lowest possible cost. myMatrixx has an online tool that claims professionals can use to manage pharmacy and clinical programs. This workers compensation PBM solution provider gives claims professionals the information they need to get the most cost-effective clinical solutions for companies.
Companies need to assess the kind of compensation their workers are likely to claim and choose a PBM with the clinical resources to handle them cost-effectively.
The Role of PBMs
Pharmacy Benefit Managers do not distribute prescription drugs, but they negotiate drug prices and payments with drug manufacturers, healthcare providers, pharmacies, and health insurance companies.
Whenever a new drug is developed, the manufacturers and wholesalers agree on a price, then the wholesalers will supply it to retail pharmacies at their price. PBMs make agreements with drug manufacturers on behalf of insurance carriers and receive rebates as part of the agreement. They also pay pharmacies for the drugs they dispense to ill or injured workers on behalf of a company's insurance carrier.
PBMs also create and maintain lists of prescription drugs that a company’s health insurance policy will cover. This list is called a formulary. Formularies often contain recommended evidence-based medication that is effective in treating various ailments. These lists exist to ensure that ill or injured workers use the most effective and affordable medication available.
However, there are times when affected workers need medicine that is not on a PBM’s formulary. In these cases, healthcare professionals are allowed to prescribe close alternatives on the list or use the drug regardless.
Workers’ compensation exists to protect and support employees who sustain injuries or fall ill because of their jobs and avoid lawsuits. It ensures that they recover quickly, do not suffer unnecessarily, and do not worsen their health because they lack access to healthcare. PBMs like myMatrixx are crucial to this effort because they help companies and insurance providers find the most cost-effective patient solutions when settling a compensation claim.