Pharmacy policy

What WorkSafe can pay for

WorkSafe Victoria (WorkSafe) can pay the reasonable costs of medications and other pharmacy items required for an accepted workers compensation claim for work-related injury or illness. This is in accordance with Victorian workers compensation legislation. It includes accepted claims for mental injury.

These guidelines exclude items covered in the WorkSafe Equipment and related services guidelines, such as bandages.

Reasonable costs can be paid directly by WorkSafe or through one of its authorised agents.

Provisional payments

All references to workers in these guidelines may also apply to workers who are entitled to provisional payments.

Eligible Victorian volunteers are also entitled to provisional payments.

Medications

WorkSafe can pay the reasonable costs of medications that meet the following criteria.

• Required as a result of a work-related injury or illness.
• Requested by a registered medical practitioner or registered dentist.
• Are provided by a registered pharmacist.
• Pharmaceutical Benefits Scheme (PBS) eligible medications when clinically appropriate.
• Non-steroidal anti-inflammatory drugs, such as gels, creams and sprays. Such drugs must be used for a period of up to 6 weeks immediately after an injury or following surgery.
• Drugs of dependence (schedule 8 medicines), and schedule 3 and schedule 4 medicines. These must meet the legal requirements around their prescribing, dispensing and clinical use. This includes the service provision of opioid replacement therapy (ORT) and Long-acting Injectable Buprenorphine (LAIB) by a registered pharmacist. Service provision includes clinical oversight and management of administering medication.
• Erectile dysfunction medication in oral or injectable form. This can be for up to a maximum of 8 intermittent use tablets or injections a month, or low dosage daily use tablets.
• Australian Register of Therapeutic Goods (ARTG) registered medicine, if there is no readily available alternative. Such medicines must be clinically appropriate treatment for the work-related injury or illness.

WorkSafe can pay the reasonable costs of non-PBS (privately prescribed) medications if the following applies:

• The medication is not available on the PBS.
• The medication is available on the PBS, but the worker does not meet the criteria for PBS prescribing.

WorkSafe may request clinical justification for private prescriptions, where there are PBS eligible medications available.

Reasonable costs that require review

WorkSafe will review and consider paying the reasonable costs of the following.

• Clinically appropriate non-PBS (privately prescribed) medications where there is no readily available alternative on the PBS.
• ‘Off label’ medications, unless it is supported by National Health and Medical Research Council (NH&MRC) level 1 or 2 evidence.
• Bulk supply of medications, such as for the purpose of overseas travel. For more than one month’s supply, an invoice needs to be sent to WorkSafe for payment processing. Invoices will be not processed through the online payment system. See WorkSafe’s Invoicing guidelines for information on what is required.
• ARTG listed complementary medicines. This includes certain vitamins and minerals, such as:
  • Vitamin C
  • Zinc
  • Vitamin E cream
  • Glucosamine
  • Hypericum (St John's Wort)
  • Vaccinium Macrocarpon (Cranberry product)

Review of a complimentary medicine claim will be based on the clinical appropriateness of the treatment.

What WorkSafe will not pay for

WorkSafe cannot pay for the following medications.

• Medications that are not clinically justified, safe and effective.
• Medications that are not reasonable, necessary or appropriate to treat the work-related injury.
• Medications that have no NH&MRC level 1 or 2 evidence that it is safe and effective. Refer to WorkSafe’s Non-established, new or emerging treatments and services policy.
• Medications recommended by a healthcare provider other than a registered medical practitioner or registered dentist.
• Medications that are not invoiced according to WorkSafe's pharmacy invoicing requirements.

How much WorkSafe will pay

WorkSafe will pay for treatment and services according to its fee schedule. If the pharmacist charges more than the WorkSafe rate, the worker may need to pay the difference. WorkSafe will pay for pharmacy and over-the-counter items in line with the PBS where applicable.

Where a pharmacist charges above the PBS rate, the worker may need to pay the difference, if it's not covered by Medicare or private health insurance. This also applies if an over-the-counter item is not on the PBS.

WorkSafe can pay for the reasonable cost of private scripts dispensed by a pharmacy. If the cost of a private script exceeds the WorkSafe rate, the worker may need to pay the difference.

For pricing and invoicing requirements, see WorkSafe's pharmacy invoicing requirements.

Who can provide medication and pharmacy items to workers

WorkSafe can pay for medication and other pharmacy items dispensed by pharmacists who are:

• registered with WorkSafe to provide pharmacy services
• registered with the Pharmacy Board of Victoria, or the equivalent in other Australian states or territories.

Pharmacies are required to register with WorkSafe. They must obtain a WorkSafe provider number to enable payment of invoices.

If a pharmacy’s name or address details change, a new provider number will need to be allocated. To update provider name or address details with WorkSafe, providers must email the new details to: [email protected].

An email confirming the changes will be sent to the requesting email address.

Suspension

If a provider is suspended from providing services to workers, WorkSafe will notify:

• the Australian Health Practitioner Regulation Agency (AHPRA)
• any relevant professional body that regulates the provider
• Medicare Australia.

The notice will include the grounds on which the suspension was issued.

Further guidance

Pharmacists

A pharmacist prepares medications and dispenses or fills prescriptions. Registered pharmacists can provide advice about the medicines a worker is taking.

Medicines and pharmacy supplies can be provided only by a registered pharmacist. Supplies may include prescription medications or other pharmacy items dispensed by pharmacists.

Controlled medicines

Medications may have associated risks. In Australia, there are systems in place to minimise these risks. These include regulations on how and when certain medications can be prescribed and administered.

Some medications, if misused or overused, have a high risk potential for:

• harm
• dependence
• accidental death from poisoning.

Controlled medications are subject to strict controls under the law. These include medications such as sedatives and opioid analgesics.

Workers prescribed a controlled medication must pay close attention to any instructions from the prescribing doctor and pharmacist. This will minimise the risks associated with taking a medication of this type.

WorkSafe encourages workers to seek further information from their medical practitioner or pharmacist.

SafeScript

SafeScript is a Victorian government software that provides access to a patient’s prescription history for high-risk medicines. It monitors all prescriptions, whether they receive a PBS subsidy or are private, non-PBS prescriptions.

Doctors, nurse practitioners and pharmacists can use SafeScript to view records of all high-risk medicines that have been supplied to patients under their care. This helps health professionals make safer and more informed clinical decisions. It also aids the co-ordination of treatment and communication by giving visibility of all clinicians involved in the prescription of identified high-risk medications.

Authorised Department of Health staff access SafeScript as part of their regulatory role.

WorkSafe and its agents do not have access to SafeScript records of workers.

Sedatives

WorkSafe can pay the reasonable costs of sedatives prescribed for short-term use of up to 4 weeks.

WorkSafe requires clinical justification before considering paying the reasonable costs of the following.

• Sedatives prescribed beyond 4 weeks.
• Privately prescribed sedatives available on the PBS.
• Two or more prescribed sedatives to be taken in the same 24-hour period.