Breaking Down the Barriers: Why Injured Workers Struggle to Receive High-Quality Pharmacy Care

May 20

Summary:

When a worker sustains an occupational injury or develops a work-related illness, prescription medications often play an important role in treatment and recovery. Workers’ compensation insurance is designed to cover medically necessary care, including medications, without copayments or deductibles, while also supporting rehabilitation and wage replacement. In theory, this structure should help ensure timely access to appropriate therapies. In practice, however, a range of administrative, clinical, and systemic factors can complicate the medication process, sometimes leading to delays in treatment and affecting recovery timelines and overall claim outcomes.

Addressing Early Barriers to Medication Access

Access to medications in workers’ compensation can be challenging early in the claim process due to gaps in coverage setup, communication breakdowns, and administrative delays. At Prodigy, proactive engagement helps address these challenges before they arise. Patients are contacted in advance and informed that Prodigy will be managing their pharmacy benefits. A pharmacy card is provided before any injury occurs, so if a work-related injury does happen, the injured worker already has the information needed to access medications without delay.

In addition, Prodigy uses a first fill formulary that allows injured workers to obtain an initial prescription while the claim is still being processed. This approach helps prevent delays at the point of care and ensures treatment can begin immediately. By reducing administrative friction early in the process, this model supports timely treatment, improves the patient experience, and promotes a more efficient path to recovery (1).

From Delays to Long-Term Claims

Barriers in the workers’ compensation system do more than delay care. They can change the trajectory of a claim over time. When access to medications is disrupted early, injured workers may experience unmanaged pain and reduced function, which can slow recovery and increase the likelihood that a straightforward injury becomes a prolonged and more complex claim.

These early disruptions often create a chain reaction. Without timely treatment, workers may delay reporting injuries, return to work too soon, or continue working without proper care, which can worsen the underlying condition and extend recovery timelines (1). As symptoms persist, treatment becomes more complex and may involve additional interventions, more medications, and greater coordination across providers.

Administrative barriers can also lead to cost shifting, where care is billed outside of the workers’ compensation system due to processing issues, reflecting broader system inefficiencies (2). Together, these factors show how small disruptions early in the process can evolve into significantly more complex and costly claims.

Managing Medication Complexity in Workers’ Compensation

Polypharmacy presents a significant risk as treatment progresses. The concurrent use of opioids with benzodiazepines, muscle relaxants, or other sedating medications increases the likelihood of adverse events and drug interactions. These prescribing patterns are also associated with higher costs and poorer outcomes in workers’ compensation claims (3).

As injured workers are exposed to multiple medications over time, managing this complexity becomes critical. At Prodigy, comprehensive clinical reviews are used to support safe and appropriate medication use. These reviews involve analyzing claims data over several months to identify medication trends, confirm which therapies are actively being used, and evaluate whether treatment aligns with best practices.

This process helps identify potential risks early, including unsafe drug combinations, duplication of therapy, and patterns of overuse. Medications are assessed for clinical appropriateness, interaction risk, and opportunities to simplify treatment. By addressing these issues proactively, clinical reviews support better patient outcomes, improve safety, and help prevent unnecessary increases in claim costs over time (4).

Moving Forward

Improving pharmacy care in workers’ compensation requires coordinated system level changes. Early access programs, including first fill strategies, can help ensure that treatment begins without delay. Streamlining prior authorization processes and improving communication between providers, pharmacies, and claims stakeholders can further reduce friction in the system. Better integration of clinical and claims data also plays an important role in enabling more informed decision making and improving coordination of care. When these barriers are addressed, injured workers are more likely to recover quickly, return to work sooner, and experience fewer complications throughout the claim.

At Prodigy, these challenges are addressed through a proactive approach that focuses on both early access and ongoing oversight. Individuals are contacted in advance and informed that Prodigy will be managing their pharmacy benefits, and they receive a pharmacy card before any injury occurs. This preparation helps ensure that, if a work-related injury happens, medications can be accessed without delay. In addition, first fill programs are used to allow injured workers to obtain their initial prescription while the claim is still being processed, helping prevent gaps in care at the most critical stage.

This combination of early engagement and continued clinical oversight helps reduce delays, improve coordination, and support better outcomes over the life of a claim. Strengthening the pharmacy pathway in this way is an essential step in improving recovery and reducing overall claim costs within the workers’ compensation system.

By Abdiaziz Haji

PharmD Candidate (P4)

L in kedIn

For questions, e-mail pharmd@prodigyrx.com

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