The Third Circuit Court of Appeal issued twin opinions in two cases related to physician dispensing of medication and employer choice of pharmacy. In Lafayette Bone and Joint Clinic v. Guy Hopkins Construction and Lafayette Bone and Joint Clinic v. Louisiana United Business SIF, the issue at hand was reimbursement for medication dispensed through Lafayette Bone and Joint Clinic. The insurer, LUBA, had issued a letter on June 5th, 2008 advising its workers’ comp claimants that the company had engaged the services of a pharmacy benefit manager (PBM) and recommending but not requiring claimants to use a retail pharmacy for their medications. Shortly after, LUBA stopped reimbursing for physician dispensed prescriptions. In the subsequent dispute before the WCJ, Guy Hopkins/LUBA argued that they had never approved the medication over the $750 threshold, because of the letter. The WCJ ruled in their favor. According to court documents, LUBA did not directly inform Lafayette Bone and Joint Clinic or the claimant of that policy.
Upon review, the Third Circuit reversed the WCJ’s decision in part. The judges explain: “it is undisputed that as of June 5, 2008, LUBA had already paid over $750.00 to Dr. Cobb [of Lafayette Bone and Joint Clinic] for the treatment of Mr. Poole [claimant]. It is also undisputed that LUBA had authorized and paid for additional office visits with Dr. Cobb after June 5, 2008, and that Mr. Poole obtained the subject medication on various dates after June 5, 2008, in connection with the authorized office visits with Dr. Cobb. Further, Paul Roy, on behalf of LUBA, testified that separate authorization for medication prescribed by an authorized treating physician is typically not required, that the medication itself was authorized, and that the medication was reasonable and necessary for the treatment of Mr. Poole. Moreover, it is undisputed that LUBA did not notify Mr. Poole that he could not obtain his medication from his treating physician. Under these facts, it was manifestly erroneous for the WCJ to conclude that the medication dispensed in connection with authorized office visits was not also authorized.” Additionally, the court awarded $3,750 in attorneys fees and $2,000 in penalties.