28 Tex. Admin. Code § 134.504 - Pharmaceutical Expenses Incurred by the Injured Employee
(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).
Notes
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