What Drugs and Medications Are Covered Under My L&I Claim?

Workplace injuries can be devastating, impacting your health, finances, and overall well-being. The workers' compensation system in Washington, often referred to as L&I, aims to provide injured workers with necessary support during their recoveries.

At Lehmbecker Law, we've witnessed firsthand the complex nature of this system. Our workers' compensation attorneys are dedicated to guiding injured workers like you through the process so that you receive the compensation you deserve.

Many injured workers have questions about whether their medications will be covered by L&I. We'll share our knowledge, explain what drugs and medications are included in L&I claims, and clarify why coverage may be limited.

L&I and Workers' Comp in Washington State

The Washington State Department of Labor & Industries (L&I) oversees the state’s workers' compensation system. This system is governed by laws like Washington Administrative Code Title 296 and Washington Revised Code Title 51.

L&I is responsible for ensuring that injured workers receive the benefits they are entitled to. The department also works to prevent workplace injuries by enforcing safety regulations and providing education and resources to employers.

Workers’ Comp Eligibility Criteria: Who Qualifies for L&I Benefits?

Washington workers' compensation laws clearly spell out who can access financial and medical support. Your injury must meet specific criteria:

• Prompt reporting: You must notify your employer soon after the injury.
• Covered employer: Your employer must be required to provide L&I coverage; most employers in Washington are, but there are exceptions (e.g., self-insured employers).
• Directly related to your job: Your injury must have occurred while performing your work duties.

For example, if you were injured on a construction site, in a scaffolding accident, or in a slip and fall in a warehouse, you could recover benefits. But if you were injured during your lunch break while off the clock, your claim would likely be denied.

What Losses Your L&I Workers' Compensation Claim Covers

By filing an L&I claim, you can receive financial and medical support during your recovery. This support might include medical treatment, wage replacement, and disability benefits.

Medical Treatment

Workers’ compensation should cover all medical treatment related to your injury:

• Doctor's appointments with L&I-approved providers
• Physical therapy to regain strength and mobility
• Medications (prescription and over-the-counter)
• Surgeries and other procedures
• Specialized therapies (like acupuncture or massage), if medically necessary

You don’t have to let your employer choose your doctor in Washington. Additionally, if your employer tries to make you take a company representative with you to medical appointments, you can decline.

Time Loss Replacement

In Washington State, L&I provides time loss benefits to help replace lost wages while you're unable to work due to your injury. This benefit is generally between 60% and 75% of your normal wage, paid out on a weekly basis.

Permanent Partial Disability

If your injury results in a permanent impairment that affects your ability to work, you may be eligible for a lump-sum payment to compensate for the change to your earning capacity.

Important L&I Claim Coverage Considerations

Not every L&I claim goes smoothly, and even a small misstep could cause a setback.

‍Remember these details:

• Pre-authorization: Always get L&I approval before receiving treatment or filling prescriptions.
• Provider number: Make sure to include your provider's number when submitting claims for medical care.
• Unrelated conditions: L&I only covers treatment directly related to your work injury; treatment for unrelated conditions will not be covered.
• Diagnostic studies: L&I will typically cover diagnostic studies like X-rays or MRIs, but only if your doctor deems them necessary.
• Occupational diseases: If you develop an occupational disease (a disease caused by your work environment), L&I may cover your medical care and lost wages.

You'll likely work with a dedicated claims manager throughout the process who can answer your questions and help you navigate the system.

L&I's Approach to Medication Coverage

L&I has specific guidelines for determining which medications are covered under a workers’ compensation claim.

Physician-Prescribed

Medications must be prescribed by a doctor who has been approved by L&I to treat workplace injuries. This means that you can't simply go to your primary care physician and expect L&I to cover the medications they prescribe. You need to work with a doctor who is part of the L&I network.

Medically Necessary

The medication must be medically necessary to treat your injury. In other words, it must be intended to help you heal from your condition or manage your symptoms. L&I won't cover medications that are not directly related to your work injury, even if your doctor prescribes them.

Approved by L&I

You can't just assume that all medications prescribed by your doctor will be covered by L&I. Usually, you will need to get pre-authorization from L&I before filling a prescription. Waiting for pre-authorization ensures that the medication will be covered under your claim and prevents you from incurring out-of-pocket expenses.

Types of Drugs and Medications that L&I Covers

You can expect medications to be approved by L&I as long as they are recommended by your work injury doctor.

Prescription Medications

L&I covers medications that require a doctor's prescription, such as antibiotics, anti-inflammatories, and certain pain relievers. For example, if your back injury requires muscle relaxants or your knee injury needs anti-inflammatory medication, L&I will likely cover these prescriptions.

Over-the-Counter Medications

Some over-the-counter medications may be covered if authorized by your doctor. For instance, your doctor may recommend ibuprofen for pain management. L&I may cover this medication even though it's available without a prescription.

Alternative Remedies

In some cases, L&I may also cover remedies or therapies that fall outside conventional medicine, such as herbal supplements, if your doctor deems them medically necessary. This coverage is not guaranteed and may be granted on a case-by-case basis.

What Medications Are Not Covered by L&I?

While L&I aims to cover necessary medications, there are some limitations to its coverage. It generally will not cover the following.

Medications for Unrelated Conditions

If you are taking medication for a condition unrelated to your workplace injury, L&I will not cover the cost. For example, if you have type 1 diabetes and need insulin, L&I will not cover this medication since it is not a work-related illness.

Medications Not Prescribed by Your Doctor

You cannot simply purchase medications at a drugstore and expect L&I to cover them. The medication must be prescribed by your doctor. This means that if you buy a pain reliever at the store without a prescription, L&I will not reimburse you.

Medications Not Deemed Medically Necessary

If your doctor prescribes medication that L&I determines is not medically necessary for your work-related injury, it may not be covered. This could include situations where the medication is considered unnecessary for your specific condition or if there are less expensive alternatives.

Reaching a Benefits Limit: Maximum Medical Improvement

As you progress through your recovery, your doctor will assess your condition and determine when you have reached maximum medical improvement (MMI). MMI means that your condition has stabilized and that any remaining medical concerns are not expected to heal further

Once you reach MMI, L&I's coverage may change:

• Medical benefits may be limited: L&I may restrict the types of medical treatments it covers after MMI, focusing instead on maintaining your current level of health.
• Further treatments may require approval: If you need additional treatment after MMI, you may need to obtain authorization from L&I.

If you disagree with your doctor’s decision about MMI, consider speaking with a workers’ compensation attorney and seeking a second medical opinion.

Continuing Your Journey: What Happens After Your L&I Claim Is Closed?

Even after your L&I claim is closed, your recovery journey might not be over. If your condition worsens or you need further treatment, you can file an Application to Reopen Claim. Through this application, you can request additional benefits.

Speak with your doctor about what information you might need for the application, and consult an attorney if you have legal questions.

Beyond L&I: When a Personal Injury Claim Is Necessary

While L&I covers workplace injuries, there are situations where a personal injury claim may be appropriate, especially if someone besides your employer caused your injury.

‍These are some examples:

• Car accidents: If you were injured in a car accident caused by another driver's negligence, you can file a claim against that driver.
• Slip and fall injuries: If you slipped and fell on someone else's property due to their negligence (like a poorly maintained floor), a personal injury claim could be an option.

Depending on your situation, you may be eligible to file both a workers’ compensation and a personal injury claim.

What Can I Ask for in a Personal Injury Claim?

In a personal injury claim, you can ask for additional benefits not available through L&I, including:

• Full lost wages: Since L&I provides just a portion of lost wages, you can seek the remaining amount through your claim.
• Pain and suffering: You can be compensated for the emotional distress and discomfort you've experienced as a result of the injury.

Like workers’ compensation claims, personal injury lawsuits have strict deadlines. Contact a personal injury attorney as soon as possible to begin building your case.

Lehmbecker Law: Your Advocate in the Face of Injury

It can be tough to figure out how L&I medication coverage works, but understanding your rights and options is key to getting the support you need during your recovery.

If you have any questions or concerns about your L&I claim, contact Lehmbecker Law. We are dedicated advocates for people like you who are dealing with workplace injuries.

Our experienced personal injury attorneys in Washington State are ready to fight for your right to compensation.