Pedestrian Struck by Vehicle: Pharmacy Lien Case Study

James Wong — Founder & Pharmacist, LienScripts | February 11, 2026 | 9 min read

An elderly pedestrian struck in a crosswalk sustained a hip fracture, wrist fracture, rib fractures, and mild TBI. Medicare was primary but left gaps — a pharmacy lien covered the non-Medicare medications throughout treatment, and the settlement navigated the Medicare Secondary Payer conditional payment process.

Case Background

Note: This is a fictionalized case study based on composite facts. Names and identifying details are not real. The clinical details represent typical medication patterns for this injury type.

Pedestrian accidents involving elderly patients present a constellation of challenges that go well beyond the acute injuries. The patient population is more vulnerable to complications, recovery timelines are longer, and the insurance landscape is more complicated — particularly when Medicare is primary. This case study follows Eleanor, a 74-year-old woman struck by a vehicle in a marked crosswalk, and demonstrates how a pharmacy lien program worked alongside Medicare to provide complete, uninterrupted medication coverage throughout a complex recovery.

[!KEY] Eleanor's case illustrates a gap that catches many attorneys off guard: Medicare covers a broad range of post-acute care, but specific medications — particularly certain compounds and non-formulary drugs — fall outside Medicare Part D coverage. A pharmacy lien fills those gaps without disrupting Medicare's primary payer status.

The Accident and Initial Injuries

Eleanor, 74, was walking in a marked crosswalk with the pedestrian signal when a driver turning right on a red light struck her. She was thrown approximately eight feet and landed on the pavement. She was transported by ambulance and admitted to the hospital.

Emergency evaluation revealed:

• Left hip fracture — displaced femoral neck fracture, treated with open reduction internal fixation (ORIF). The surgery was performed within 24 hours of admission, as is standard of care for displaced hip fractures in elderly patients.
• Right distal radius fracture — a classic fall-on-outstretched-hand injury as she braced against impact, treated with closed reduction and percutaneous pin fixation (CRPP)
• Right-sided rib fractures (ribs 5, 6, and 7) — treated conservatively with pain management and pulmonary hygiene; no pneumothorax
• Mild traumatic brain injury — brief loss of consciousness at scene, post-concussive symptoms including persistent headache, cognitive slowing, and dizziness through month 2

Eleanor was discharged to a skilled nursing facility (SNF) for post-acute rehabilitation after a five-day hospital stay. She spent six weeks in the SNF before transitioning to outpatient physical and occupational therapy.

Medicare as Primary Payer: Coverage and Gaps

Eleanor had Medicare Parts A, B, and D as her primary insurance. Her attorney noted this at intake and initiated the Medicare Secondary Payer (MSP) coordination process immediately — a step that is legally required when a Medicare beneficiary is injured by a third party.

Medicare Part A covered the hospitalization. Medicare Part B covered most of the outpatient physician services during recovery. Medicare Part D, through her prescription drug plan, covered the majority of her medications.

However, Medicare Part D does not cover everything. The gaps in Eleanor's case included:

Non-formulary compounded medications: Eleanor's pain management physician prescribed a low-dose naltrexone compound for adjunctive pain management during her recovery. Compounded medications are not covered by Medicare Part D.

Topical compound for rib pain: A compounded lidocaine and diclofenac topical was prescribed for the rib fracture pain — topical application was preferred because Eleanor had mild renal insufficiency that made high-dose systemic NSAIDs a prescribing concern. Compounded topicals are not covered by Medicare.

Medications subject to Part D prior authorization denial: Eleanor's Part D plan placed trazodone — prescribed for sleep disruption related to her TBI — on a tier requiring a prior authorization that the plan denied on the first attempt. While the appeal was pending, the pharmacy lien covered the medication without interruption.

Wrist pin-site wound care supplies: Certain wound care supplies associated with her distal radius pin sites fell outside Medicare coverage and were tracked through the pharmacy record.

[!KEY] Medicare Part D prior authorization denials are common, especially for medications requiring step therapy or clinical justification. A pharmacy lien provides uninterrupted coverage during the appeals period — preventing the patient from going without a prescribed medication while the insurer processes paperwork.

The Pharmacy Lien Structure

Eleanor's attorney enrolled her in a LienScripts pharmacy lien to cover the non-Medicare medications. The lien was structured carefully to avoid any overlap with Medicare's primary payer status — it covered only medications and supplies that Medicare Part D had either denied, excluded, or was pending authorization on.

This distinction matters legally. A pharmacy lien that attempts to cover medications already covered by Medicare raises Medicare Secondary Payer compliance concerns. By limiting the lien to genuine gap medications, the program operated cleanly alongside Medicare without triggering coordination-of-benefits complications.

The lien covered:

• Compounded low-dose naltrexone for adjunctive pain management
• Compounded lidocaine and diclofenac topical for rib fracture pain
• Trazodone during the Part D prior authorization appeal period (Medicare resumed coverage after approval)
• Wound care supplies for wrist pin sites

Eleanor's Medicare-covered medications — including post-surgical hydrocodone/acetaminophen for acute pain, gabapentin for post-concussive headache management, and standard formulary fills — were billed through Medicare normally and did not appear in the pharmacy lien record.

The Medicare Secondary Payer Process at Settlement

This is the section of pedestrian accident cases that many attorneys underestimate in complexity. When Medicare has paid for any medical care related to a personal injury accident, the Medicare Secondary Payer statute creates a federal obligation to reimburse Medicare from settlement proceeds. Failure to do so can result in double damages and attorney liability.

The MSP process in Eleanor's case involved several structured steps.

Conditional payment identification: Eleanor's attorney submitted an MSP query to the Benefits Coordination and Recovery Center (BCRC) early in the case, identifying the accident date, injury types, and the anticipated third-party claim. Medicare began tracking conditional payments — payments it made that were related to the injury — from that point forward.

Conditional payment amount: At the time of settlement negotiations, the BCRC provided a conditional payment amount reflecting the Medicare payments made for Eleanor's hospitalization, SNF stay, outpatient therapy, and covered medications. This was a significant figure, as Medicare had covered substantial acute and post-acute care.

Negotiating the conditional payment: Eleanor's attorney worked with a Medicare Secondary Payer compliance specialist to negotiate the conditional payment amount down based on proportionality principles and procurement cost deductions. The final conditional payment was meaningfully reduced from the initial BCRC demand.

Settlement waterfall: The settlement waterfall at resolution included attorney fees and costs, the negotiated Medicare conditional payment, the pharmacy lien amount covering the non-Medicare gap medications, and Eleanor's net recovery. Each obligation was a distinct line item resolved through its appropriate channel.

The pharmacy lien amount — covering only the genuinely non-Medicare medications — was modest relative to the Medicare conditional payment. But it was a separate obligation with its own resolution track, handled independently from the MSP process.

[!KEY] In Medicare beneficiary pedestrian accident cases, the pharmacy lien and the Medicare conditional payment are two separate obligations at settlement. The pharmacy lien covers non-Medicare medications and resolves with the pharmacy. The Medicare conditional payment resolves with the BCRC through the MSP process. Conflating them creates compliance exposure.

The Medication Record's Evidentiary Role

Eleanor's attorney used the pharmacy lien medication record — covering the non-Medicare gap medications — in conjunction with the Medicare remittance records to build a complete picture of Eleanor's pharmacological treatment burden. The combined documentation showed:

• The scope and duration of post-surgical pain management, including the clinical rationale for non-standard formulations driven by Eleanor's renal insufficiency
• The psychiatric impact of the injury, documented through the trazodone record across multiple months
• The clinical complexity that drove non-standard medication choices — renal insufficiency requiring topical rather than systemic NSAID application — which demonstrated the seriousness of her pre-existing comorbidities relative to the injury's demands
• Future medication costs for ongoing adjunctive pain management for residual hip and wrist discomfort

The at-fault driver's insurer, confronted with a complete and organized medication record alongside Medicare remittance data, was unable to credibly argue that Eleanor's treatment was excessive or that her ongoing medication needs were speculative.

Key Takeaways for Attorneys

1. Identify Medicare status at intake and initiate MSP coordination immediately. The conditional payment clock starts at the accident date. Early BCRC notification and query submission reduces surprise at settlement and allows for conditional payment amount tracking throughout the case.

2. A pharmacy lien for Medicare patients should cover only the genuine coverage gaps. Structuring the lien to exclude Medicare-covered medications maintains MSP compliance and avoids double-billing complications. Work with your pharmacy lien provider to confirm that the lien is limited to non-covered and non-formulary medications.

3. Compounded medications are almost always outside Medicare Part D. For elderly patients with comorbidities that require non-standard formulations — such as compounded topicals to avoid systemic NSAID risk from renal insufficiency — a pharmacy lien is often the only available coverage for those medications.

4. The two obligations resolve on separate tracks. At settlement, the pharmacy lien and the Medicare conditional payment are distinct obligations handled through different processes. Build the settlement waterfall to address both, with appropriate Medicare Secondary Payer compliance counsel on the MSP side.

Related Resources

• What Is a Medicare Set-Aside in Personal Injury?
• Pharmacy Lien: No Out-of-Pocket Cost for Injured Patients
• Compound Medications in Personal Injury
• Pedestrian Accident Medications and Pharmacy Lien
• Low-Dose Naltrexone for Chronic Pain in Personal Injury