Case Study: Denying Medication that has Been Approved for Decades

Women looking at pill bottle

Patient DJ was injured in September of 2003. DJ is established for multiple sites of injury, including the neck, back and left shoulder. DJ has been receiving multiple medications for pain for DECADES that have been covered and paid.

DJ was using diclofenac 1% topical gel for over a year when the NYS WCB Pharmacy formulary was released. The diclofenac was then denied by the insurance carrier first as NON-FORMULARY and then as not part of the medical treatment guidelines. Both denials are incorrect. Diclofenac is a formulary drug and a mainstay in multiple medical treatment guidelines.

The medication was last authorized in September 2019. After that, monthly attempts to bill through the network pharmacy have been denied. Multiple conversations with the adjuster at the insurance carrier resulted in always the same denial: Diclofenac was not a formulary drug (this is incorrect). The prescriber had to get a medical portal (this is incorrect). We were also told given incorrect details about the medical treatment guidelines.

Titan Pharmacy finally developed a relationship with the Deputy Executive Director of the NYS WCB and escalated the situation to them. The medication was authorized and paid for on November 18th, 2020, over a year later.

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