Workers' Compensation Prescription Drug Program
SCOPE: The Vermont Purchasing and Contract Administration Division is seeking to establish a
purchasing agreement with a company that can implement a pharmacy discount and utilization
review service for the State of Vermonts Workers Compensation program. The State of Vermont
Risk Management Division will utilize this contract.
BACKGROUND: The State of Vermont began self-insuring and self-administering its workers
compensation exposure on February 1, 1990. All workers compensation claims filed by state
employees injured on the job are handled by the States Risk Management Division (RMD). RMDs
workers compensation section includes four teams, each consisting of a medical case manager
(MCM) and a claims adjuster (Adjuster) who work together to manage the claims and ensure
appropriate and quality medical care for the injured workers.
Currently all medical billing (including pharmacy items) is submitted to RMD where the claims staff
reviews the invoices for approval and then forwards them to a bill-paying contractor for processing.
The bill-payer processes the payment, creates an explanation of benefits (EOB), and mails the check
and EOB to the pharmacy/provider. There are no pharmacy discounts in place at this time.
The reason for considering implementing a pharmacy program for the states workers
compensation claimants is to help control the cost of prescription drugs by providing claimants with
convenient access to a network of preferred pharmacies that offer discounts while also managing
outcomes and decreasing inappropriate utilization.
