Request For Injured Worker Outpatient Medication Reimbursement {BWC-1122}

en-USRequest for Injured Worker Outpatienten-USMedication Reimbursement 225 þ en-USThe pharmacy can process a point-of-sale transaction to avoid the need to submit the en-USC-17. 225 þ en-USThe attachment of prescription labels with pricing information or a pharmacy printout en-USwith pricing information is required. Photocopies are acceptable. Cash register receipts en-USare not suf037cient. 225 þ en-USPharmacist222s signature and date are required. 225 þ en-USInjured workers only use this form for reimbursement of outpatient medication. 225 þ en-USThere is a one-year statute of limitations for reimbursement from date of service. 225 þ en-USIf the injured worker uses more than one pharmacy to 037ll prescriptions, he or she must en-USsubmit a separate C-17 for each pharmacy. 225 þ en-USBill medical supplies, durable medical equipment and other non-drug items on a sepaen-US-en-USrate invoice to the managed care organization (MCO). To identify the correct MCO, please en-USlog on to en-USwww.bwc.ohio.gov,en-US or call en-US1-800-644-6292,en-US and listen to the options. 225 þ en-USThe amount paid will be pursuant to the approved BWC fee schedule for drugs. 225 þ en-USFor drugs that are available generically, BWC will reimburse the fee schedule amount en-USassigned to that drug, as described in Ohio Administrative Code 4123-6-21. If you or your en-USphysician requested the brand-name version of a drug when a generic drug was availen-US-en-USable, BWC will reimburse at the maximum allowable cost for the drug. BWC bases reimen-US-en-USbursement on the cost of the generic drug. 225 þ en-USMedications, including over-the-counter items, must be prescribed by a medical profesen-US-en-USsional licensed to prescribe drugs and dispensed by a pharmacy provider enrolled with en-USBWC. Drugs purchased from a physician222s of037ce for at-home use are not reimbursable. 225 þ en-USMail completed form to: en-USChange Healthcareen-USP.O. Box 769en-USAugusta, ME 04332 225 þ en-USFor additional information, or if you need help to complete this form, contact a Change en-USHealthcare customer service representative by calling 1-800-644-6292 and listening to en-USthe options.en-USCheck list þ en-USHave you 037lled out the C-17 completely for processing? þ en-USHave you completed the Injured worker information section? þ en-USHave you signed and dated the form? þ en-USHas the pharmacy completed the Pharmacy information and Prescription detail en-USsections? þ en-USHas the pharmacist signed and dated the form? þ en-USHave you included pharmacy labels with pricing information or a pharmacy printouten-US en-USwith en-USpricing information as required? Cash register receipts are not suf037cient. en-USBWC-1122 (Rev. Jan. 08, 2019)en-USC-17 American LegalNet, Inc. www.FormsWorkFlow.com en-USDate of request en-USDate Rx writtenen-USPrescriber's nameen-USPrescriber NPI numberen-USPrescription numberen-USDate dispenseden-USNational drug codeen-USDrug name, strength and dosage formen-USMetric quantityen-USEstimated days supply en-USRe037llen-USYES en-USNO en-USTotal charge en-USPharmacist's signature en-US(Required)en-USI certify below the information on this form is true and correct to the best of my knowledge and belief.en-USBWC-1122 (Rev. Jan. 08, 2019)en-USC-17en-USDate en-USInjured worker informationen-USDate of injuryen-USBWC claim numberen-US en-US(Required)en-USInjured worker nameen-US en-US(last, 037rst, middle initial)en-USInjured worker addressen-US en-US(street or PO Box, city, state, and nine-digit ZIP code) en-USPharmacy en-US(name and store number) en-USPharmacy informationen-USNPI numberen-US en-US(Required)en-USPharmacy phoneen-USPharmacy addressen-US en-US(street or P.O. Box, city, state, and nine-digit ZIP code) en-USPrescription detail en-USPharmacist en-USDate Rx writtenen-USPrescriber's nameen-USPrescriber NPI numberen-USPrescription numberen-USDate dispenseden-USNational drug codeen-USDrug name, strength and dosage formen-USMetric quantityen-USEstimated days supply en-USRe037llen-USYES en-USNO en-USTotal charge en-USDate Rx writtenen-USPrescriber's nameen-USPrescriber NPI numberen-USPrescription numberen-USDate dispenseden-USNational drug codeen-USDrug name, strength and dosage formen-USMetric quantityen-USEstimated days supply en-USRe037llen-USYES en-USNO en-USTotal charge en-USDate Rx writtenen-USPrescriber's nameen-USPrescriber NPI numberen-USPrescription numberen-USDate dispenseden-USNational drug codeen-USDrug name, strength and dosage formen-USMetric quantityen-USEstimated days supply en-USRe037llen-USYES en-USNO en-USTotal chargeen-USen-USen-USen-USRequest for Injured Worker Outpatient en-USMedication Reimbursement en-USInjured worker's signature en-US(Required)en-USI certify below the information on this form is true and correct to the best of my knowledge and belief.en-USDate en-USInjured worker www.FormsWorkFlow.com