Highlights of Noteworthy Decisions

Decision 1545 14
21/08/2014
M. Crystal
  • Suitable employment
  • Health care (medical aid) (drug formulary)

A hotel room attendant suffered chest wall injury when she slipped and fell. The worker appealed a decision of the Appeals Resolution Officer denying LOE benefits from March 4 to 10, 2012, and denying entitlement for the drug Vimovo.

The employer offered suitable modified work. The worker was not entitled to LOE benefits during the period in question.
Vimovo is a drug that combines an anti-inflammatory medication and a medication that provides gastro-intestinal protection. It is not on the Board's drug formulary. Generally, where corresponding generic drugs are on the formulary, the generic drugs should be deemed to meet the test of being necessary, sufficient and appropriate, and more expensive non-generic drugs will not meet that test. In this case, there was no persuasive evidence that the worker tried the separate generic versions of the two drugs that are combined in Vimovo. The worker was not entitled to reimbursement for Vimovo.
The appeal was dismissed.