WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 1318/16 BEFORE: S. Netten: Vice-Chair HEARING: May 3, 2016 at Toronto Written Post-hearing activity completed on June 22, 2016 DATE OF DECISION: June 29, 2016 NEUTRAL CITATION: 2016 ONWSIAT 1747 DECISION UNDER APPEAL: WSIB Appeals Resolution Officer decision dated December 3, 2014 APPEARANCES: For the worker: For the employer: Interpreter: L. Dillon, Lawyer Not participating None Workplace Safety and Insurance Appeals Tribunal Tribunal d appel de la sécurité professionnelle et de l assurance contre les accidents du travail 505 University Avenue 7 th Floor 505, avenue University, 7 e étage Toronto ON M5G 2P2 Toronto ON M5G 2P2
Decision No. 1318/16 REASONS (i) Issue [1] The issue under appeal is the worker s entitlement to payment of prescription medication. (ii) Overview [2] In April 2012, an Appeals Resolution Officer (ARO) granted the worker entitlement to an ongoing psychological condition arising from workplace injuries of November 14, 2005 and September 16, 2006. At that point the Board had already been funding anti-depressant medication for the worker; it appears that Cipralex was first approved in 2009, and it was funded until August 2012. In November 2012, the Board confirmed a decision not to pay for Cipralex, as well as Cymbalta, and provided the worker with a list of alternative medications which were on the Board s drug formulary. [3] The worker s objection to this decision was addressed by an ARO in December 2014, who confirmed ongoing entitlement for the psychological condition but denied entitlement for the two prescription medications. [4] The worker now appeals to the Tribunal. This appeal was selected for a written hearing pursuant to the Tribunal s Practice Direction: Written Appeals. The worker s representative provided written submissions dated October 30, 2015, outlining the worker s treatment history and the need for Cipralex as the only safe and reliable medication to treat the worker s depressive disorder. In response to my request for supplemental submissions, on June 21, 2016 the worker s representative advised that his client is not seeking entitlement to Cymbalta (which he does not take); he has had coverage for Cipralex through his spouse and is consequently not seeking retrospective entitlement; and he is content with prospective entitlement to the generic version of Escitalopram, which has been prescribed since 2014. (iii) Law and policy [5] The Workplace Safety and Insurance Act, 1997 ( WSIA ) applies to this appeal. [6] Health care is defined in section 32 of the WSIA to include drugs. Entitlement to health care is governed by section 33: 33(1) A worker who sustains an injury is entitled to such health care as may be necessary, appropriate and sufficient as a result of the injury (7) The Board shall determine all questions concerning, (a) the necessity, appropriateness and sufficiency of health care provided to a worker or that may be provided to a worker; and (b) payment for health care provided to a worker. [7] The standard of proof applicable in workers compensation proceedings is the balance of probabilities. The benefit of the doubt is given to the claimant in resolving an issue where the evidence for and against is approximately equal in weight.
Page: 2 Decision No. 1318/16 (iv) Discussion [8] There is no dispute in this appeal that the worker is entitled to health care benefits for a compensable psychological condition, including anti-depressant prescription medication. In denying entitlement to Cipralex, the Board indicated that an anti-depressant on the Board s drug formulary would be covered. Prescription records confirm that the Board did pay for prescriptions for one of these alternatives, Wellbutrin, in September and December 2012. [9] The reason for the denial of Cipralex was because it was not found on the Board s drug formulary. The Formulary Drug Listing Decision, dated January 29, 2013, compared Escitalopram to other second generation anti-depressants and found no clinically important differences, and similar adverse events. At that time the only version of Escitalopram available was the brand name drug Cipralex. Explaining their recommendation not to list Escitalopram/Cipralex on the formulary, the Drug Advisory Committee wrote as follows: No pharmacoeconomic studies relevant to the WSIB were identified. Less costly but equally effective antidepressants such as sertraline, citalopram, bupropion and venlafaxine are currently listed on the WSIB formularies. Current evidence does not warrant recommending any particular SGA on the basis of differences in efficacy or safety. Since escitalopram is priced at a premium, there is insufficient evidence to demonstrate value over other generic SSRIs on WSIB formularies. Key guidelines recommend initiating antidepressant therapy with any SSRI as a first-line agent. All agents are considered equally effective and have a similarly favourable risk-benefit ratio. Based on the available evidence, the DAC concluded that there was no compelling evidence demonstrating a therapeutic or non-therapeutic advantage for escitalopram over other SGA comparators in the treatment of MDD. Furthermore, several alternatives are available on the WSIB formularies that can meet the treatment needs of the majority of injured/ill workers. Hence, the DAC recommended that escitalopram not be listed on any WSIB formularies. [10] Section 33(7) of the WSIA directs the Board to determine all questions concerning the necessity, appropriateness and sufficiency of health care that may be provided to a worker. Moreover, the purpose of the WSIA, set out in section 1, is to provide benefits to workers (among other objectives) in a financially responsible and accountable manner. I consider the use of an expert committee which reviews the medical literature on the efficacy, safety and cost-effectiveness of prescription medications to be a reasonable method to determine the general necessity, appropriateness and sufficiency of such medications. As noted in Decision No. 2157/14, such generally applicable conclusions need not apply in every case, and there may be exceptional circumstances which indicate that non-formulary prescriptions are necessary or appropriate for an individual worker. [11] As outlined in the formulary decision on Escitalopram, there are no concerns about its efficacy or safety. Then available only as the brand name drug Cipralex, Escitalopram was excluded solely for reasons of cost-effectiveness. However, the situation in this respect has evolved, and Escitalopram is evidently now available in a generic version, prescribed to the worker since November 2014 ( Ran-Escitalopram, Co-Escitalopram and Apo-Escitalopram ). Moreover, upon forwarding to the Tribunal the Formulary Drug Listing Decision on June 13, 2016, the Legal Services Division wrote the formulary will be updated as the generic version of the medication was added this year.
Page: 3 Decision No. 1318/16 [12] The worker s prescription records indicate that in 2014 the cost of Cipralex (excluding dispensing fees) was $1.94 per 10 mg tab; at a dosage of 20 mg daily, the cost was approximately $116 per month. In comparison, the cost of the generic Escitalopram in 2014 was $0.47 per 10 mg tab, or approximately $28 per month. Wellbutrin, which the Board funded as an alternative within its formulary, cost $20.64 for a one-month supply (excluding dispensing fee) in 2012. [13] I am satisfied that Escitalopram, in its generic versions, is no longer priced at a premium as it was in January 2013 (when the Formulary Drug Listing Decision was issued). Consequently, the basis for denying entitlement to this medication is no longer applicable. I find that the worker is entitled to payment of a generic version of Escitalopram, from the date of this decision and ongoing, for so long as it is prescribed and required for a compensable psychological condition. Funding is thus subject to the usual medication reviews. [14] I note that this decision does not preclude the Board from determining the most cost-effective way of funding this medication. For example, the worker s prescription records indicate that a month s supply of 20 mg tabs of Cipralex was close to half the cost of a month s supply of 10 mg tabs; it may be that similar cost savings are achieved if the worker is prescribed half the number of 20 mg tabs of the generic Escitalopram (provided, of course, that he continues to take the full 20 mg each morning, as previously prescribed).
Page: 4 Decision No. 1318/16 DISPOSITION [15] The appeal is allowed. The worker has prospective entitlement to payment for a generic version of Escitalopram, from the date of this decision and ongoing, for so long as it is prescribed and required for a compensable psychological condition, and subject to the Board s usual medication reviews in this respect. DATED: June 29, 2016 SIGNED: S. Netten