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| Q:
What is impairment? [Top] |
| Impairment is a loss
of anatomical structure, or a loss of anatomical or physiological
function that has a recognized pathophysiological basis. |
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| Q:
What is (work-related) disability?
[Top] |
| A work-related disability
is an inability to perform pre-accident job demands arising
from a workplace injury.
While the use of the term 'disability' differs
from the World Health Organization (WHO) definition, it is
keeping with general use amongst clinicians and insurance
companies. The WHO defines 'disability' as an inability
to perform specific tasks, and 'handicap' as an inability
to function within certain roles such as inability to perform
pre-accident work. |
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| Q:
What drugs does WorksafeNB cover?
[Top]
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In general, WorksafeNB
covers any drugs related to the treatment of the accepted work-related
injury or illness. WorksafeNB does place a limit on the extent
to which it will cover certain classes of drugs:
- Anxiolytics and sedatives
are generally limited to claimants with seizures and spasticity
due to spinal cord injuries
Where a generic substitute is
available, WorksafeNB would prefer that it be used in place of
a more expensive brand name. Your cooperation in reducing
medical aid costs is appreciated.
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Q: What is a claimant’s “default formulary”? [Top] |
Lost time claims are electronically assigned a default formulary at the time of claim acceptance. No lost time claims are electronically assigned a default formulary when a request is made to pay for a prescription.
The default “primary” formulary is electronically assigned based nature of injury (NOI) obtained from Form 8, 8C or 8N/I. Drug classes are assigned to a formulary based on generally accepted treatment within the acute and subacute injury phases. If the diagnosis or clinical impression is too vague, the claimant may be assigned the “null” formulary – no associated drug classes. In other cases, WorksafeNB’s NOI categories do not provide meaningful direction as to the appropriate primary formulary. The claimant is initially assigned the “null” formulary.
The medical advisor can change a claimant’s primary formulary if it does not meet the claimant’s needs. Or, the medical advisor may use special authorization or secondary mini-formularies to address a claimant’s needs.
Q: What is the difference between special authorization and a formulary? [Top] |
Formularies were built using drug classes. Generally any drug within a drug class is included within the formulary. An exception would be that “hydromorphone” is not included with other opioids. It has its own mini-formulary. An exception to the “hydromorphone” mini-formulary is that it does not contain “Dilaudid”.
Special authorization (SA) is DIN-specific. Where applicable, interchangeable products can be substituted. If the dose changes, a new SA is required.
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| Q:
Does WorksafeNB cover OTC drugs?
[Top] |
WorksafeNB covers OTC drugs
related to the treatment of the accepted work-related injury
or illness. The pharmacist requires a prescription to submit a bill to WorksafeNB.
For example, if your patient will benefit
from plain acetaminophen or ASA, WorksafeNB would prefer that you
prescribe these rather than resort to combination medications
with codeine.
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Q: What is opioid management? [Top] |
In November 2007, WorksafeNB implemented opioid management as part of its due diligence responsibility to workers. WorksafeNB data showed that as impairment decreased the percentage of prescriptions increased and the percentage of prescriptions exceeding generally recommended quantity limits also increased. These increases are greater for claimants with a predominantly psychosocial pain generator.
There is a duration trigger for claimants on the basic MSK formulary (W2), and a 30-day quantity trigger for opioids in all formularies. The duration trigger is an automatic one-time trigger. It is activated 6 weeks after the date of accident. A prescription after 6 weeks triggers a review. If additional opioids are indicated, the medical advisor reinstate them using either mini-formulary or special authorization.
Each opioid is assigned to a group. Each group has a collective 30-day quantity limit with 3 days grace. If the 30-day quantity is exhausted before the 3 days grace, the pharmacist will get a message that the claimant has reached the quantity limit. Unlike the Medicare system, you do not need to do anything if the prescription is fully covered. Every 30 days the “basket” is replenished until the authorization termination date is reached. At this point, the pharmacist will be informed that the opioid is no longer a benefit.
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Q: Does WorksafeNB cover antidepressants? [Top] |
WorksafeNB covers antidepressants for the treatment of chronic pain related to the accepted work-related injury or illness. Guidelines recommend starting with tricyclics. This class of antidepressants is included in the basic MSK formulary W2. If the claimant is unable to tolerate tricyclics or has partial improvement with tricyclics but side-effects preclude further increase in dose, the Medical Advisor may authorize the use the use of an SSRI or SNRI.
Q: Does WorksafeNB cover GI cytoprotective agents? [Top] |
The literature suggests that the greatest risk for NSAID-induced GI bleeding is within the first two weeks in persons with a high-risk profile. The Medical Letter suggests that proton pump inhibitors are the best agents at preventing GI bleeding; and that newer ones are not more efficacious than omeprazole. The default formularies contact omeprazole. If there is evidence that this is not effective for your patient, the Medical Advisor may authorize a different cytoprotectant.
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Q: What is neuropathic pain drug management? [Top] |
In 2009, WorksafeNB found an increasing trend in prescribing gabapentin and pregabalin for non-neuropathic pain. By late 2009, WorksafeNB will use the DN4 Questionnaire to identify which claimants meet a case definition for neuropathic pain (NP). WorksafeNB will pay for gabapentin and pregabalin if the claimant’s pain is consistent with the DN4 case definition for NP.
Payment for the first prescription will be the trigger. These drugs have not been in the default formularies since the start of ePay in 2004. Payment for the first prescription has traditionally been rejected and a medical advisor has had to review the medical information to decide whether or not to authorize payment. What changes in late 2009 is the addition of requirement for certain information from the pharmacist and physician in order to make the authorization decision; the use of up to 3 months trial; and the use of the Québec Pain Disability Questionnaire to validate functional improvement by the end of trial.
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Q: Does WorksafeNB cover new drugs? [Top] |
It depends on the nature of the new drug. If the new drug is a different brand of a drug already covered, this is generally automatically added to the formularies.
If the new drug is a new class of drug or a totally new drug within an existing class of drugs, the Chief Medical Officer will review The Medical Letter and other literature to determine whether or not the new drug will be added to WorksafeNB formularies.
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Q: Does WorksafeNB cover 1st aid supplies? [Top] |
WorksafeNB covers most 1st aid supplies – alcohol solutions and wipes; antiseptic solutions, soaps, cleansers; hydrogen peroxide; dressings; tape; bandages; gloves.
These are included in the spinal cord injury formulary, minor wounds and burns formulary, major wounds and burns formulary, and the skin disorders formulary.
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Q: Does WorksafeNB cover urinary catheter supplies? [Top] |
WorksafeNB covers urinary catheters, gels, urinary supplies, urine bags and incontinence pads.
These must be added individually as special authorizations or collectively as a
mini-formulary.
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Q: What investigations, treatments and procedures does WS-NB cover? [Top] |
In general, WorksafeNB covers any referrals, investigations, treatments and procedures related to the treatment of the accepted work-related injury or illness.
WorksafeNB may not cover treatment by a specific provider or provider group. For an up-to-date listing, contact your patient's claim adjudicator or case manager through the enquiry line.
WorksafeNB generally requires research-based proof of efficacy from peer-reviewed journals, for non-standard investigations and treatments.
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| Q:
Does WorksafeNB cover
anxiolytics and sedatives? [Top] |
| With the general exception
of anxiolytics for seizures and spasticity due to spinal cord
injuries, WorksafeNB does not cover these therapeutic classes of
drugs. |
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| Q:
Does WorksafeNB cover antidepressants?
[Top]
|
| WorksafeNB covers antidepressants
for the treatment of chronic pain related to the accepted work-related
injury or illness. |
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| Q:
What investigations,
treatments and procedures does WHSCC cover? [Top]
|
| In
general, WorksafeNB covers any referrals, investigations, treatments
and procedures related to the treatment of the accepted work-related
injury or illness. However, WorksafeNB may not cover treatment
by a specific provider or provider group.
For example:
a physiotherapy clinic may not be on its list of authorized
clinics (for an up-to-date listing, contact your patient's
claim adjudicator or case manager through the enquiry
line. While a physiotherapist may provide massage
therapy as one component of a physiotherapy treatment plan,
WorksafeNB does not cover massage therapists. Currently the
only complementary or alternative medicine service covered
by WHSCC is acupuncture, and that coverage is limited to specific
providers (for an up-to-date listing, contact your patient's
claim adjudicator or case manager through the enquiry
line.
To ensure that
the cost of your patient's referral, investigation, treatment
or procedure is covered, you should contact your patient's
claim adjudicator or case manager through the enquiry line. |
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| Q:
When
do I have to get pre-authorization for payment of referrals,
investigations, treatments and procedures? [Top] |
| Except
for emergencies, you should get prior authorization to cover
the costs of any referral or major investigation, treatment
or procedure. To get authorization please contact your
patient's claim adjudicator or case manager through the enquiry line. Prior authorization is
not required for routine blood work, X-rays and minor procedures
such as trigger point and joint injections. |
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| Q:
What services
does the Workers' Rehab Centre offer? [Top] |
| WRC
provides an expertise in medical assessments, work conditioning,
work recovery, prosthetics and orthotics, and
vocational evaluation. For more information, see the Workers' Rehabilitation Centre (NB)
website. |
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| Q:
Does
WorksafeNB cover alternative or complementary medicine services?
[Top]
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WorksafeNB covers some types of alternative or complementary medicine services for the treatment of chronic pain. For an up-to-date listing, contact your patient's claim adjudicator or case manager through the enquiry line.
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Q: What is the P&A Questionnaire? [Top] |
The P&A (Pain and Activity) Questionnaire is a self-report tool that WorksafeNB is using to identify claimants at risk for prolonged disability due to psychosocial factors. Research shows that cognitive-behavioural approaches can reduce the impact of these factors on biological pain and effectiveness of biological-based treatments. Unless addressed, biological-based treatment can be ineffective resulting in escalation to treatment with a greater potential for harm.
For more information, see your clinician information binder.
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Q: How does WorksafeNB evaluate treatment effectiveness? [Top] |
Effective treatment should improve function. WorksafeNB uses the validated self-report Québec Pain Disability Questionnaire and the SF-36 to validate functional improvement.
For more information, see your clinician information binder.
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Q: How do I get a clinician’s information binder? [Top] |
WorksafeNB has produced information binders for physicians, chiropractors and nurse practitioners. Contact the Chief Medical Officer to obtain a binder. |
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