Ohio > Workers Comp > Injured Workers
Request For Injured Worker Outpatient Medication Reimbursement BWC-1122 - Ohio
| Request For Injured Worker Outpatient Medication Reimbursement Form. This is a Ohio form and can be used in Injured Workers Workers Comp . |
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Request for Injured Worker Outpatient Medication Reimbursement · · · · · · · · · · · · The pharmacy can process a point of sale transaction to avoid the need to submit the C-17. The attachment of prescription labels with pricing information or a pharmacy printout with pricing information is required. Photocopies are acceptable. Cash register receipts are not suficient. Pharmacist's signature and date are required. Injured workers only use this form for reimbursement of outpatient medication. There is a two-year statute of limitations for reimbursement. If the injured worker uses more than one pharmacy to ill prescriptions, he or she must submit a separate C-17 for each pharmacy. Bill medical supplies, durable medical equipment and other non-drug items on a separate invoice to the managed care organization (MCO). To identify the correct MCO, please log on to ohiobwc.com, or call 1-800-OHIOBWC, and listen to the options. The amount paid will be pursuant to the approved BWC fee schedule for drugs. For drugs that are available generically, BWC will reimburse the maximum allowable cost amount assigned to that drug. If you or your physician requested the brand-name version of a drug when a generic drug was available, BWC will reimburse at the maximum allowable cost for the drug, which is based on the cost of the generic drug. Medications, including over-the-counter items, must be prescribed by a medical professional licensed to prescribe drugs and dispensed by a pharmacy provider enrolled with BWC. Drugs purchased from a physician's ofice for at-home use are not reimbursable. Compounded drugs are not reimbursable. Mail completed form to: SXC Health Solutions P.O. Box 5226 Lisle, IL 60532-5226 · For additional information, or if you need help to complete this form, please contact an SXC customer service representative by calling 1-800-OHIOBWC and listening to the options. Check List Is the C-17 illed out completely for processing? Have you completed the Injured Worker Information section? Has the Injured Worker signed and dated the form? Has the pharmacy completed the Pharmacy Information and Prescription Detail sections? Has the pharmacist signed and dated the form? Have you included pharmacy labels with pricing information or a pharmacy printout with pricing information as required? Cash register receipts are not suficient. American LegalNet, Inc. www.FormsWorkFlow.com Request for Injured Worker Outpatient Medication Reimbursement Injured Worker Information Date of request Injured worker name (last, first, middle initial) Injured worker address (street or PO Box, city, state, and nine-digit ZIP code) Date of injury BWC claim number (Required) Pharmacy Information Pharmacy (name and store number) NABP/NCPDP number (Required) Pharmacy phone Pharmacy address (street or P.O. Box, city, state, and nine-digit ZIP code) Prescription Detail Date Rx written Date dispensed Metric quantity Prescriber's name National drug code Estimated days supply Reill YES Date Rx written Date dispensed Metric quantity Prescriber's name National drug code Estimated days supply Reill YES Date Rx written Date dispensed Metric quantity Prescriber's name National drug code Estimated days supply Reill YES Date Rx written Date dispensed Metric quantity Prescriber's name National drug code Estimated days supply Reill YES NO Prescriber NPI number Drug name, strength and dosage form Total charge Prescription number NO Prescriber NPI number Drug name, strength and dosage form Total charge Prescription number NO Prescriber NPI number Drug name, strength and dosage form Total charge Prescription number NO Prescriber NPI number Drug name, strength and dosage form Total charge Prescription number Injured Worker I certify below the information on this form is true and correct to the best of my knowledge and belief. Injured worker's signature (Required) Date Pharmacist I certify below the information on this form is true and correct to the best of my knowledge and belief. Pharmacist's signature (Required) Date BWC-1122 (Rev. 12/15/2009) C-17 American LegalNet, Inc. www.FormsWorkFlow.com
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