If you’ve been in the workers’ comp world for any length of time, you’ve probably had this exact headache. You’re looking at the numbers, and the pharmacy costs just don’t make sense. You’ve set up a solid pharmacy network, you’ve got a PBM partner, and everything should be running smoothly.
And yet, the leaks are there. Costs are higher than they should be. You see prescriptions being filled at places you’ve never heard of, for prices that make you wince.
It’s a challenge we’ve been trying to solve for years. So often, we look at the system, the technology, or the providers for an answer. But what if the most important—and most overlooked—partner in this whole equation is the injured worker themselves?
Why Do They Go "Off the Grid" for Prescriptions?
Let’s be honest. When someone gets hurt on the job, their first thought isn’t about pharmacy network utilization. Their first thought is, "I'm in pain, and I need to get better." That’s it. Everything else is just noise.
And in that noise, it’s incredibly easy for them to end up filling their prescriptions "out-of-network" (OON). It’s not usually a malicious choice. Most of the time, they don’t even realize they’re doing it or why it matters.
I’ve seen this play out in a few common ways:
1. The Doctor Just Hands Them the Pills This is a big one: physician dispensing. Imagine you’re at the doctor’s office after an injury. You’re stressed, you’re in pain, and at the end of the appointment, the doctor says, "Here, I have the medication you need right here."
Are you going to say no? Of course not! It’s convenient. You don’t have to make another stop. But in that moment, the injured worker often has no idea they even had the option to ask for a written prescription to take to their local, in-network pharmacy. The choice was made for them, and they were just trying to follow doctor's orders.
2. The Siren Song of Convenience Then you have the OON mail-order pharmacies. They can feel like a lifesaver to someone who is recovering at home and has trouble getting around. A few clicks, and the medication shows up at their door. It’s the Amazon Prime effect.
The problem is, these services often operate outside the payer's network, leading to higher costs and less oversight. The worker just sees an easy solution to their problem, not the back-end complexities it creates.
3. Simple Frustration Let’s not forget the power of a bad experience. If an injured worker tries to use an in-network pharmacy and their prescription gets delayed or, even worse, denied at the counter, what do you think they’ll do next time? They’re going to find a path of less resistance.
Frustration is a powerful motivator. If going out-of-network feels easier or more reliable, that’s the path they’ll take, and frankly, it’s hard to blame them.
This Isn't Just a Numbers Problem
It's easy to look at OON pharmacy use as just a line item on a spreadsheet—a cost control issue. But the impact goes deeper than that, and it can even affect the injured worker’s recovery.
When a prescription is filled within the network, there are checks and balances. The Pharmacy Benefit Manager (PBM) can flag potential drug interactions, inappropriate dosages, or other clinical red flags. It’s a safety net.
When a worker goes OON, that safety net disappears. We lose visibility into what’s being prescribed and filled, which can create risks for the patient. So, getting them back into the network isn't just about saving money; it’s about better, safer care.
The Solution Starts with a Simple Conversation
So, how do we fix this? We can’t just send out a memo and expect behavior to change. The answer, I truly believe, lies in treating the injured worker like the partner they are. It’s about direct engagement.
Think about it. We spend so much time communicating about the injured worker—with adjusters, case managers, and attorneys—but how much time do we spend communicating with them about this stuff?
Empowering them with simple, clear information can make a world of difference. It’s not about giving them a lecture on PBMs and network contracts. It’s about having a real conversation:
- Explain the "Why": "Hey, we have a network of pharmacies we work with. Using them makes everything smoother—approvals are faster, you won’t have to pay out-of-pocket, and we can make sure your medications are safe."
- Make It Easy: "Here is your prescription card. Just show this at any CVS or Walgreens, and you'll be all set. Here’s a list of the closest ones to your house."
- Give Them a Choice: "Your doctor might offer you medications in the office, and that’s fine, but you always have the right to ask for a written prescription if you’d prefer to use your local pharmacy."
When we bring the injured worker into the process, we’re not just pushing them toward compliance; we’re giving them a sense of control over their own recovery. We’re turning them from a passive recipient of care into an active participant.
And time and time again, we’ve seen that when people feel empowered and informed, they make better choices—for their own health and for the system as a whole. It’s a small shift in approach, but it can play a massive role in finally getting those leaky pharmacy costs under control.
