Workers' Compensation

Prescription Drug Trends for 2013 Include Hard Pills to Swallow

The recently released research from pharmacy benefit manager The Express Scripts Lab in the “2013 Workers’ Compensation Drug Trend Report”  is equivalent to the State of the Union regarding prescription drug benefits for injured workers. These conclusions reflect data from workers’ compensation payers which are Express Scripts clients.

The featured takeaways included:

> The Top 10 therapy classes of drugs constituted nearly 84 percent of the total spent on prescription drugs in workers’ compensation in 2013.

> The average annual prescription drug cost per injured worker in 2013 was slightly over $1,603.

> The average price for a prescription rose 8.2 percent between 2012 and 2013.

> The per-user price of narcotic analgesics, which Express Scripts identified as the most expensive therapy class, did not increase from the 2012 annual rate of $512.93/user.

> Compounded drugs made their debut in the Top 10 therapy classes based on the annual per-user cost in 2013.

> The overall spending on anticonvulsants, which medical professionals also used for neuropathic pain, rose 13 percent.

> A 21.5 percent increase in spending on non-steroidal anti-inflammatory drugs, commonly referred to as NSAID, to alleviate pain and inflammation resulted in a $146.05 annual cost per user.

Recap of Opioid Prescription Issues

The data regarding opioids included that prescribing long-acting drugs in that class increased the odds of the total cost of a workers’ compensation claim exceeding $100,000. This research concluded as well that 84 percent of the amount that was spent on those drugs that year was for prescriptions for 20 percent of injured workers.

The findings regarding the effectiveness of efforts to combat the well-known problems related to opioid prescriptions included the impact of relevant state and federal policies not always aligning. A cited case of that non-alignment was imposing stricter controls on a single-ingredient hydrocodone product than on a combination hydrocodone product. Express Scripts reported that the response of the FDA has included considering a reclassification that would change hydrocodone combination drugs from a Schedule III substance to a Schedule II medication.

The shared statistics included the related findings that 63.2 percent of workers who sustained compensable harm received at least one opioid prescription in 2013 but that the annual per-user utilization of these substances was lower for the third consecutive year. The report concluded that that decrease reflected the effectiveness of efforts that specifically addressed opioid abuse.

Compounded Drugs

In addressing compounding pharmacies, the report noted that the board of health of the state where they were based regulated them and that FDA oversight was limited. A provided example of the laissez-faire approach of the federal government was that the FDA did not subject compounded drugs to the mandatory “rigorous drug review process” that helped ensure that “commercially available prescription drugs” were adequately safe and effective to warrant the necessary FDA approval. The report added that compounded drugs typically lacked standard dosages and did not always have standard protocols regarding their preparation.

Concerns regarding the relatively loose standards regarding compounded drugs included:

> Variations between batches of them;

> Possibly inadequate sterility and purity; and

> Prescription costs that often significantly exceeded those of “similar commercially available products.”

Specific research results included that 2.1 percent of the 153,000 doctors who provided the data on which Express Scripts based the report prescribed compounded drugs.

This study also cited the statistic that there was a 151-percent median-price increase in the amount that “high-compounding pharmacies” charged for compounded products from 2012 to 2013. This increase regarding pharmacies that dispensed fewer than 67 percent of their prescriptions in the form of compounded drugs was 71 percent for the compounded drugs that they dispensed.

Express Scripts provided additional data regarding decreases in the number of prescriptions per injured worker for compounded drugs in 2013 compared to 2012. The states that Express Scripts included in this portion of the research had a minimum of 50 injured workers who received compounded drugs in 2013.

The results included that the quantity of injured workers who received a prescription for at least one compounded prescription increased in every state that met the threshold of having at least 50 injured workers who received those drugs in 2013; on average, the percentage of those workers who received a prescription for that type of drug rose from one percent in 2012 to two percent in 2013. The average cost of each of those prescriptions was roughly $1,300.

The ranking of the five states (out of 16 states that were reviewed) with the largest decreases in the number of these prescriptions per injured worker between 2012 and 2013 were:

> California, which had a 19.2 percent decrease in the amount of prescriptions for compounded drugs per injured worker;

> Pennsylvania, which had an 18.8 percent decrease in the amount of prescriptions for compounded drugs per injured worker;

> Illinois, which had an 11.2 percent decrease in the amount of prescriptions for compounded drugs per injured worker;

> Alabama, which had a 7.8 percent decrease in the amount of prescriptions for compounded drugs per injured worker; and

> New York, which had a .4 percent decrease in the amount of prescriptions for compounded drugs per injured worker.

Specialty Medications

Express Scripts described specialty medications as usually expensive and complex drugs that typically required both regular dosing adjustments and close clinical monitoring. Issues related to using those drugs within workers’ compensation include the alarming pace at which the costs of those medications were rising despite the fact that they comprised less than one percent of the prescribed drugs within the workers’ compensation system.

The research revealed that the annual per-user cost of a prescribed specialty medication was roughly $2,385. The average per-prescription cost of these drugs was just over $1,119, which was almost nine times more than the cost of other classes of prescriptions that included narcotics and anticonvulsants.

Out-of-Network and Third-Party Biller Prescriptions

The report concisely summarized another contributor to higher-than-necessary workers’ compensation prescription drug costs by stating that injured workers using out-of-network pharmacies or not notifying either an in-network pharmacy or their pharmacy benefit manager of a prescription created avoidable costs in the forms of higher pharmacy expenses and third-party biller costs without providing any corresponding additional value.

Express Scripts estimated that the aggregate waste associated with using out-of-network pharmacies and third-party billers was $40 million each year; associated research showed that using home delivery for drugs that treated chronic conditions reduced prescription drug costs.

Age-of-Injury Effect

The reported findings regarding the phenomenon of the costs of prescription drugs greatly increasing as a percentage of the total expense of a workers’ compensation claim as that claim aged included that:

> The average per-prescription cost was roughly $59 for the first year of a claim in 2013;

> That amount nearly doubled by the third year of a claim; and

> The amount leveled off at an annual cost of $150 approximately 10 years after a compensable incident.

Related findings indicated that an inverse relationship between the age of a claim and the generic fill rate (GFR) was one reason for the tendency for per-prescription costs to increase during the first 10 years of that claim. The provided statistics showed that the GFR was 91.3 percent during the first year of a claim and fell to 73.4 percent during the 10th year after an injured worker sustained compensable harm. Speculation regarding that trend included the possibility that generic drugs became less effective over the life of an injury.

Prescription for Monetary Relief

One lesson from the copious data in the report is that educating physicians about proper prescription practices is critical. Another takeaway is that injured workers and administrators of the insurance plans that compensate for employment-related harm must utilize good practices in having those prescriptions filled.

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