Certain medication prescribed to an injured worker under the Workers Compensation scheme are classified as “high risk medications”.
The governing body in charge of regulating the NSW workers compensation, SIRA, classifies certain medication as having the potential for negative health outcomes, dependence and accidental overdose based on current research evidence.
The guidance offered by SIRA includes a focus on the following high-risk medication:
- Opioids
- medication-assisted treatment of opioid dependency (MATOD)
- injectable narcotics
- benzodiazepines and z drugs
- medicinal cannabis.
If you have been prescribed this treatment due to a workplace injury, your workers compensation insurer may pay for such treatment.
Will My Treatment Be Covered Under Workers Compensation?
Under the Medication management in the NSW personal injury schemes: Better practice guide, generally speaking, medications:
- Must be for the treatment of the person’s compensable injury;
- Must be prescribed by a legally qualified medical practitioner or dentist registered with Australian Health Practitioner Regulation Agency (AHPRA) under the Health Practitioner Regulation National Law;
- Must be supplied by a registered pharmacist;
- Should be prescribed and supplied through the PBS system unless the medication is not available on the PBS or there are extenuating circumstances.
Should your medication be classified as “high risk”, SIRA provides further recommendation to the workers compensation insurer in monitoring the treatment outcomes associated with this medication.
The importance of “high risk medication” are particularly relevant with the Therapeutic Goods Administration’s recent decision to change classification of medicines containing psilocybin and MDMA to substances of medicinal treatment for certain psychological and/or psychiatric conditions. Parallels can be drawn with medicinal cannabis.
As show in Janice-Marie Longworth v Secretary, Department of Transport [2020] NSWWCC 52, notwithstanding the insurer’s arguments that medicinal cannabis was experimental, not registered and was still undergoing clinical trials (at that time), the relatively novel nature of the treatment still fell within the definition of “medical or related treatment” under the scheme.
Despite the difference in treatment, it is foreseen that decisions relating to medicinal cannabis will be utilised to demonstrate medicines containing psilocybin and MDMA fall within the scheme.
It is expected, however, that there will likely be pushback against such arguments from the insurer’s perspective.
If It Is Covered, What Is Needed for Approval?
When determining whether the workers compensation insurer is liable to pay your “high risk medication”, the treatment must be reasonably necessary for the treatment and management of your illness.
The Workers Compensation Guidelines refers to the following factors when determining whether treatment is reasonably necessary:
- the appropriateness of the particular treatment.
- the availability of alternative treatment.
- the cost of the treatment.
- the actual or potential effectiveness of the treatment.
- the acceptance of the treatment by medical experts.
Whether the treatment is reasonably necessary varies on a case-by-case basis and the ultimate insight will be observed by the medical opinion, whether it be your treating doctor and an independent doctor.
Other preconditions also apply.
Get In Touch With Us
It is in our experience that high risk medication treatment will likely be met with opposition from the workers compensation insurer.
At Turner Freeman, we have lawyers dedicated in specialising in compensation. Our lawyers will assess your case and provide personalised advice regarding your legal entitlements and will act for you on a “no win, no fee” basis. For further information contact us today on 13 43 63.