Request For Injured Worker Outpatient Medication Reimbursement Injured Worker Information Date or request BWC claim number (Required) Date of injury Injured worker Social Security number (Optional) Injured worker name (last, first, middle initial) Injured worker address (street or PO Box, city, state, and nine-digit ZIP code) 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 Prescriber's name Prescriber's DEA number (Optional) Date dispensed National drug code Drug name, strength, and dosage form Metric quantity Estimated days supply Refill YES Prescription number Total charge NO Date Rx written Prescriber's name Prescriber's DEA number (Optional) Date dispensed National drug code Drug name, strength, and dosage form Metric quantity Estimated days supply Refill YES Prescription number Total charge NO Date Rx written Prescriber's name Prescriber's DEA number (Optional) Date dispensed National drug code Drug name, strength, and dosage form Metric quantity Estimated days supply Refill YES Prescription number Total charge NO Date Rx written Prescriber's name Prescriber's DEA number (Optional) Date dispensed National drug code Drug name, strength, and dosage form Metric quantity Estimated days supply Refill YES Prescription number Total charge NO 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) BWC-1122 (Rev. 2/15/2008) C-17 Date American LegalNet, Inc. www.FormsWorkflow.com Request for Injured Worker Outpatient Medication Reimbursement (C-17) • • The pharmacy can process a point of sale transaction to avoid the need to submit the C-17. The Ohio Bureau of Workers Compensation (BWC) will not reimburse for co-payment(s) paid by the injured worker as a result of a group health insurer having been billed for a medication. The pharmacy must reverse the original payment and resubmit the entire claim to ACS State Healthcare (ACS) online. • 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 sufficient. • 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 fill prescriptions, he or she must submit a separate C-17 form 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 follow 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 office for athome use are not reimbursable. • Compounded drugs are not reimbursable. • Mail completed form to: ACS State Healthcare P.O. Box 967 Henderson, N.C. 27536-0967 • For additional information, or if you need help to complete this form, please contact an ACS customer service representative by calling 1-800-OHIOBWC, and follow the options. Check List Is the C-17 form filled out completely for processing? Have you completed the Injured Worker Information section? 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 sufficient. American LegalNet, Inc. www.FormsWorkflow.com