Is it legal for Pennsylvania workers comp. to charge recipients a copay for medications that will be refunded at a later time?

Asked about 2 years ago - Sewickley, PA

pa state uses comp services to administer their workers comp. I am charged a copay for my meds through my state retirement pharmacy benefit card and I am told I will be reimbursed within 45 days automatically by the pa state. However, this reimbursement does not automatically happen. Then, I am told to send documentation of my prescriptions to workers comp so they can verify my medications or I will not get my copays reimbursed. I also received a tax form from the pa state which I understand I am to pay taxes on these copays which I have already paid taxes on since it was my own money in the first place and it is just being loaned to them and now I am being reimbursed. This does not seem correct to me. could I be misunderstanding the work comp law of pa?

Attorney answers (6)

  1. Michael John Mueller

    Contributor Level 5

    6

    Lawyers agree

    Answered . You should give your pharmacy your workers' compensation claim number and your adjuster's information. You should not have to pay anything. No co-pays, no reimbursements. In fact, CompServices gets a discount if they pay the pharmacy directly. The way your adjuster set this up is wasteful, in both time and money.

    As far as the tax goes, you are correct. Under no circumstance is workers' compensation taxable. You can ask CompServices to issue a corrected tax form to show that you owe nothing. Good Luck!

  2. John Francis Kennedy

    Contributor Level 10

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    Best Answer
    chosen by asker

    Answered . No. They are not supposed to bill you directly for any medical care, and then promise reimbursement later. This is technically a violation of the Workers' Compensation law in Pennsylvania in my opinion, but they have been doing this for many years.

    I have represented a few people who were injured when working for the Commonwealth of Pennsylvania and this has happened to every single client. You do have options. You could try to use a mail order pharmacy that will deliver the scripts directly to your door, and then they bill the state directly. Then you have no co-pays that you must pay. But be careful. Sometimes the mail order companies will allow a big past due bill to build up, and if your lawyer is not on top of it, you could get a big bill in the mail. The employer would have to pay it, but there is a bit of a risk there.

    You could also file a penalty petition under the law, and take the case in front of a Judge. I did that, and the attorney for the state agreed that they would fix the problem, but in a few months we were back to square one, and the pharmacy was demanding a co-pay, and my client was waiting for reimbursement.

    In my experience, the state just follows a script, or a guideline, and they refuse to budge, and their lawyers will say "This is how we do it on all of the other cases." And their lawyer will say: "What's the big deal, they get reimbursed?!"

    Well, in my opinion, it is a big deal. When the injured worker is surviving on less money, every penny counts. And the injured worker should not have to wait 45 days for reimbursement, or keep track of it. Stuff falls through the cracks all the time.

    The law says that the employer is responsible for reasonable and needed medical treatment, and there is no law that allows them to ask you to pay any co-payments.

    And don't let your lawyer be threatened or strong-armed into accepting this arrangement. You need to file a penalty petition (or several petitions) to get
    them to do it the right way, or simply use a mail order company for your scripts.

    You could file a penalty petition online yourself (but I don't recommend it). The link for the online penalty petition is below.

    I would be glad to help you. Call me if you have any questions. Good luck and don't back down!

    Attorney John Kennedy
    1-800-372-0344

  3. Michael Scott Mednick

    Contributor Level 9

    4

    Lawyers agree

    Answered . You should not have to pay a co-pay. Maybe consider using a different pharmacy. Summit Pharmacy will take your claim number and mail you the RX. Others will do the leg work for you.

    Even if you are getting paid, you should have a lawyer to consult with. My firm will not charge a fee unless the employer denies you benefits or takes you to Court to stop paying you. So it is like getting free advice when you need it and a lawyer ready to fight for you if the employer tries to deny or stop paying you. Call me at 215-545-1870 if you wish to discuss your case.

  4. Timothy D. Belt

    Contributor Level 13

    3

    Lawyers agree

    Answered . I agree with the other posts, but would also suggest that if this problem continues, you may wish to contact one of the WC mail order pharmacies. They deal directly with the carrier for you and take the hassle out of the situation. Your lawyer may have a company he prefers or if you do not have an attorney, I would be happy to provide you with the phone numbers for a couple of these programs.

    Timothy D. Belt, Esquire Helping injured workers in Northeast Pennsylvania. belt-law@belt-law.com www.belt-... more
  5. Robert L. Cullen

    Pro

    Contributor Level 13

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    Answered . Some good answers from Michael, Michael, Timothy and John. The Bureau has some additional information available for you on their web site re: medical treatment that can be found by going to:

    Web: http://www.portal.state.pa.us/portal/server.pt?...

    Bottom line, stop using your private insurance, give you pharmacy the adjuster's contact information and hire an attorney to file a Penalty Petition when they refute to pay as required by the Act.

    Best of luck to you re: this!

  6. George Ellis Corson IV

    Contributor Level 20

    3

    Lawyers agree

    Answered . Probably not. Medical providers normally cannot demand payment from WC patients, and have to bill Insurance.

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