10 Reasons to Include a Pharmacy Nurse in Your Workers' Compensation Program


A recent survey of public health experts predicted 650,000 people could die from opioid misuse within the next 10 years.1 Public health spending is falling short, medication-assisted treatment is too rare, and the worst drug overdose epidemic in U.S. history is culling our labor force. Rising medical costs and the opioid epidemic aren’t new trends to our industry, and while there are many beneficial tools being implemented to address these issues there is also one you may be less familiar with – a pharmacy nurse.

What is a pharmacy nurse?

Pharmacy nurses are specially trained case managers who focus on at-risk claims due to emerging and complex pharmacy utilization, and communicate with prescribing physicians, injured workers, and claims handlers to positively impact drug utilization by using a wider lens to manage all aspects of the claim.

Here are 10 reasons to include this powerful resource in any pharmacy program.

1.       Proactive Patient Engagement

Engaging a pharmacy nurse as soon as potential risks are identified is the most proactive approach to patient education and safety. A pharmacy nurse can work quickly to identify concerning medications to reduce the likelihood of addiction. During early narcotic intervention, pharmacy nurses can call the prescriber to discuss alternative treatment plans to influence future prescribing habits and decrease narcotic utilization. From first opioid utilization through discontinuation, a pharmacy nurse can support patients at each step of therapy, advocating for the safe and effective discontinuation of opioids for injured workers.

2.       Full Medication Review

The role of a pharmacy nurse involves reviewing all medications being used along with available medication history to initiate a conversation with the provider and modify prescribing behavior where needed. A medication review may uncover opportunities for generic substitution or therapeutic intervention. In addition, therapeutic duplication, drug interactions, and polypharmacy can be addressed. An analysis of drug treatment and prescribing patterns, along with patient demographic information and categorized loss information can also determine the most appropriate candidates for pharmacy nurse intervention.

3.       Provider Outreach

A typical pharmacy nurse intervention involves contact with the prescriber, including discussions on the medication(s) in question, education regarding medication cost and potential dangers, and request for prescriber agreements with recommended changes. Upon completion, claims handlers are notified of intervention results, and appropriate edits are placed in the point-of-sale system to impact future transactions. The pharmacy nurse also facilitates ongoing provider outreach.

4.       Educating Injured Workers

Educating the injured worker is a key role of the pharmacy nurse and includes ongoing patient engagement to provide educational materials, answer questions, and ensure compliance with an appropriate medication regimen. Pharmacy nurses provide patient education on safe and appropriate use of medications including co-morbid medications, contraindications, and benefits and risks. They also work with injured workers on medication reconciliation, to introduce complimentary alternative medicine, and identify non-medical risk factors.

5.       Pharmacy Benefit Management Collaboration

While most employers and payers utilize PBMs, which offer an excellent line of defense in addressing workers’ comp pharmacy challenges, PBMs can only manage the pharmacy related aspects of a claim. The inclusion of a pharmacy nurse can extend the reach of a PBM by combining it with the knowledge, care, and one-on-one delivery model used in case management. Pharmacy nurse involvement may be initiated by a variety of PBM triggers.

6.       Partnering with Case Management

A pharmacy nurse can provide support to an assigned field or telephonic case manager. While the case manager generally manages the overall medical treatment a pharmacy nurse can assist when complex pharmacy issues are identified. This can be especially helpful to a case manager whose expertise isn’t specific to pharmaceuticals or opioid utilization. Having a specialty nurse focusing on the pharmacy portion can be of significant help to the case manager. Additionally, while not all claims require ongoing case management, some may benefit from the attention of a pharmacy nurse when the remaining issues are solved.

7.       High Dollar Medicare Set-Asides

A workers’ comp Medicare Set-aside Allocation (MSA) estimates every possible future medical expense related to the injury, including prescriptions. This amount is put into a special MSA account, and all medical expenses for the designated injury that would normally be covered by Medicare are paid from that account. Pharmacy nurses can assist in assessing appropriateness and cost effectiveness of the pharmacy costs associated with an MSA, and claims handlers can refer cases for review of the medical necessity of the medication projection.

In addition, the Centers for Medicare & Medicaid Services (CMS) will consider changes in an injured worker’s treatment and prescription regime even after an MSA has previously been submitted and reviewed by CMS. Pharmacy nurses can review high dollar MSAs to identify and negotiate an updated treatment plan.

8.       Specialty Medications

Pharmacy nurses play an important role when specialty drugs are prescribed. These drugs represent high-cost medications such as biologics, biosimilars, and injectables used to treat complex, chronic conditions and often require special handling. In conjunction with specialty pharmacy services a pharmacy nurse can address specialty medication questions and urgent concerns. Pharmacy nurses can identify plans of action and collaborate with the PBM team, prescriber, and patient to ensure the right drug is being utilized for the patient’s specific condition and availability of less costly alternatives are evaluated.

9.       Provider Noncompliance

Pharmacy nurses are also able to assist with provider noncompliance issues including providers who are non-responsive, there has been no success with an agreement to change a treatment plan, or there is an agreement but there has been no follow-through. A pharmacy nurse can provide additional resources to claims handlers such as recommending a drug utilization assessment with peer-to-peer review, independent medical exam, utilization review, or a field case management task to assist in facilitating an agreement.

10.   Savings

Workers’ comp pharmacy costs represent approximately 18% of total medical spend. That translates to $5 billion in pharmacy spend nationwide.2 Pharmacy nurses offer savings by reducing the number of high-cost medications, providing prescription review, addressing early opioid use, and negotiating MSA reductions. Savings on claims where a pharmacy nurse was used have been shown to surpass those claims without the same involvement year over year.3 Similarly, programs utilizing pharmacy nurse capabilities have experienced 10:1 return on investment and deliver an average savings of $200k per MSA claim.


Pharmacy nurses add value by managing the various components of an employee’s care. Benefits include improved patient outcomes, patient education and safety, reduced disability durations, shorter recovery times to promote return-to-work, reductions in potential addiction issues, lower claim costs, and reduced financial impacts of MSAs. If you haven’t yet considered a pharmacy nurse to complement your pharmacy benefit management program, maybe this is a 2020 resolution to consider?

1. Managed Care (June 28, 2017) Opioid Overdoses Could Claim 650,000 Lives in the Next Decade. See, https://www.managedcaremag.com/dailynews/20170628/opioid-overdoses-could-claim-650000-lives-next-decade

2.NCCI (2013) Workers Compensation Prescription Drug Study: 2013 Update. See, https://www.ncci.com/Articles/Documents/II_Prescription_Drug_Study-NCCI_AIS_2013.pdf

3. The Sounding Board (November 26, 2019). See, https://blogs.coventrywcs.com/2019/11/26/pharmacy-nurse-when-specialized-attention-is-whats-needed/


By Tammy Bradly

Tammy Bradly is the Vice President of Clinical Product Development for Coventry and has over 30 years of industry experience. Her expertise includes medical case management, disability management, and the integration of health, disability, and workers' compensation. Tammy is responsible for strategic planning and product development for clinical products and is a contributing author to Coventry’s Blog The Sounding Board.


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