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The pharmacist and the claim

Fostering awareness in the complex world of prescription drugs

It is vital for a claims administrator to have pharmacists on staff because the current reality in workers’ compensation injury care is that prescription drug activity is a dangerous and highly complex business. There are many reasons the system is prone to failure:

  • Providers balance large numbers of patients
  • Physicians and patients can be incentivized by profit motives
  • Opioid use disorder, misuse of opioid medications, is an increasing diagnosis
  • Providers have inconsistent communication protocols and disconnected operating systems

Systematic indicators are necessary to consistently alert a pharmacist employed by the claims administrator when a prescription is not a fit for the diagnosis or if it is not a fit for the acute or chronic stage of the injury. Also, automated indicators are necessary to connect the pharmacist to a claim that has multiple prescribers, adverse drug combinations or unsafe dosages.


Pharmacists routinely established in claims management practices act as sentinels, identifying multiple prescribers, dangerous combinations of medications, polypharmacy and unsafe dosages. They raise and sustain awareness among the prescribers, patients, claims examiners and nurse case managers involved in claims.

For injured workers with long-term prescription drug use, pharmacists develop and individualize weaning plans and help facilitate tapering protocols by working with prescribers. They work alongside an interdisciplinary team to ensure safe and successful tapering of not only opioids, but other medications that may have withdrawal potential. Pharmacists also help identify drug-drug and drug-disease interactions in the claim profile and also against the injured employee’s  personal medical history.

Pharmacists play a pivotal role in prescriber and injured worker education regarding drug safety. The pharmacist’s input will drive the optimal outcome for an independent medical examination needed on a claim that includes prescription drug use.

Physician/pharmacist collaboration

Physicians and pharmacists working together on claims administration programs should be organized to facilitate collaboration and effective application of their respective skills for prescription drug management.

Pharmacist intervention can include:

  • Discuss medication-related issues with the treating provider
  • Discuss long-term usage of dangerous opioids, benzodiazepines, muscle relaxers and hypnotics
  • Discuss state-specific guidelines regarding opioid doses (morphine equivalent doses/MED), opioid monitoring and combinations of controlled substances
  • Develop weaning protocol based on guidelines and patient status
  • Work with the provider to safely wean the patient off of medications in order to avoid withdrawals or relapse

MD intervention can include:

  • Discuss patient’s occupational and non-occupational diagnoses
  • Discuss treating physician’s current treatment plan and recommendations
  • Discuss opioid monitoring tools such as urine drug screens
  • Make recommendations for improved patient safety and monitoring

Real-life application of pharmacy expertise

A claim was referred to a staff pharmacist because of increasing morphine dosage levels in the injured worker’s prescriptions. As the MED rapidly escalated, the injured worker experienced an increasing level of pain and was convinced that the pain would never decrease. He was being treated by four different specialty physicians and at times had his refills authorized by a receptionist without professional consultation.

The pharmacist was assigned, she reviewed the case and reached out to all of the injured worker’s prescribers, quickly contacting all but one. Two of the physicians were unaware of employee’s medication fill history and another one continued care from the previous provider. Through a series of physician outreach attempts and multiple peer-to-peer consultations, full awareness was achieved and a uniform treatment plan was created for the patient. Within months after implementation of the treatment plan, this individual was weaned from dangerous medications and the remaining medications were maintained at safe dosages. He also reported a decrease in pain intensity and there was an overall improvement in his psychosocial behavior.


A successful pharmacist intervention identifies unsafe areas, educates stakeholders, enables awareness, partners with the claims examiner and any assigned nurse case manager, and establishes a plan to wean an injured worker from unnecessary or unsafe prescription drugs, helping return them to a healthy, productive life and activity in the workplace. In today’s complex workers’ compensation environment, the pharmacist’s role is a necessity.

Dr. Reema Hammoud, PharmD, BCPS, Director, Clinical Pharmacy 

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