Forms, Reports, Checklists
Temporary Prescription Form
An employee who has been injured or becomes ill due to a work-related incident should be given a temporary prescription form from the workers’ compensation carriers pharmacy benefit manager (PBM) when he or she reports the injury/illness. See below to download the form.
There will be instances when an employee seeks treatment before the injury can be reported, for example, a deputy on the night shift or a highway maintenance worker plowing snow on the weekend. These situations fall outside of the requirement to use the PBM’s prescription form, but the goal is to have the injured worker use the PBM as soon as possible.
Make Access to Temporary Prescription Form Easy
To ensure that workers who require medications for work-related injuries/illnesses have easy access to the temporary prescription form and do not have to pay for prescriptions out of pocket, employers are encourage to:
- Provide the temporary prescription form to every department head and supervisor to whom an employee might report a work-related injury or illness. They should be instructed to share the form with employees when they report a work-related injury or illness to their supervisors.
- Advise all employees about the prescription program and its purpose for use to treat work-related injuries and illnesses only (it’s not part of their health insurance benefit plan).
- Post temporary form in easy-to-access places. Members should use the organization’s intranet, staff meetings, staff newsletter and other means to make the temporary prescription form available in an area where employees gather (highway maintenance shop, dispatch or department bulletin boards).
If the temporary prescription form is used and the prescription is not eligible for workers’ compensation benefits, there is no cost to the employee or the employer.
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