"The pharmacy wants me to pay for my medication."

Why it happens

The claim hasn't been accepted yet. The most common reason. But even then, § 5402(c) requires the claims administrator to authorize up to $10,000 in treatment from the date you filed the claim form until it is accepted or rejected — and that includes prescriptions. Say the words "five-four-oh-two-c" to the adjuster. It changes the conversation.

The medication isn't on the formulary. California has a workers' compensation drug formulary under Labor Code § 5307.27. Drugs listed as exempt are dispensed without prior authorization; non-exempt drugs need it first. This is a paperwork problem, not a refusal — your doctor submits a request and it goes through utilization review.

The pharmacy isn't set up for the carrier. Some pharmacies do not bill workers' compensation, or do not have the claim on file. Ask the adjuster which pharmacy network the carrier uses.

Prior authorization is pending. Common with opioids, compounded medications, and anything expensive.

Nobody sent the pharmacy the claim number. More common than any of the above.

What to do, in order

1. Call the adjuster and ask for the claim number, the carrier's pharmacy benefit manager, and the network pharmacy. Write down who you spoke to and when.

2. If the claim is filed but not accepted, cite § 5402(c) and the $10,000.

3. Ask your doctor's office to submit the authorization request if the drug is non-exempt. They do this routinely; it usually just has not been done.

4. If you have already paid out of pocket — keep every receipt. Reimbursement is available for self-procured medication for an industrial injury, and receipts are the whole claim. Submit them in writing.

5. If it is denied through utilization review, the clock to request independent medical review is short — and on this page it is the shorter one. § 4610.5(h)(1)(A) gives you 10 days where the dispute is only about drugs on the MTUS Drug List; § 4610.5(h)(1)(B) gives 30 days for everything else. Miss it and the dispute is over. (One exception: under § 4610.5(h)(3), if the denial did not enclose the IMR application form and an addressed envelope, the clock never started.) How to challenge a denial.

If you cannot wait

Tell your doctor you cannot fill it. There is often an exempt alternative that does not require authorization, and a physician who does not know you are going without will assume you are taking it — which changes what they write in the report.

And say it to the adjuster in writing. A documented refusal to authorize necessary medication is evidence, and delay in providing treatment can carry penalties under § 5814. What delay is worth.