If you are suffering from a work-related injury, it is sometimes necessary to pay for urgent, prescription medication out-of-pocket. Following proper workers’ comp filing procedures as soon as you can helps ensure that you are reimbursed for those medical payments. In some cases, there may an option to have pharmacies receive reimbursements directly so you have no initial expense.
As the Ohio Bureau of Workers’ Compensation (BWC) specifies, your pharmacist may send your billing information to the Pharmacy Benefits Manager (PBM) with Form C-17, Outpatient Medication Invoice. After the BWC approves your claim, reimbursement may be sent to you or to your pharmacy, depending on how the billing information was filed.
If you use your health insurance to cover your prescription and your plan requires a co-payment, unfortunately, there is no way to receive reimbursement for that amount. You can avoid co-payments by having the pharmacist submit a C-17 form to the PBM instead of paying for prescription meds through your health insurance coverage. Check with the pharmacist on your first visit to ensure the form is filled out and sent.
Some medications require prior authorization before the prescription can be filled. Your pharmacist should be able to contact the PBM to obtain the authorization.
Following are some of the other rules that apply to prescription medication coverage under workers’ comp:
- Pharmacies can avoid using C-17 forms by processing point-of-sale transactions, which require pharmacy printouts with pricing information, pharmacists’ signatures and dates and outpatient only medications.
- Pharmacists must use C-17 forms when injured workers use more than one pharmacy to fill prescriptions.
- A one-year statute of limitations exists from the date of service for prescription reimbursement.
- Your pharmacy provider must be enrolled with the BWC.
Mail Order Pharmacies
Many injured individuals will pay for their medications themselves and then be reimbursed later by their insurance company. Of course, this option does not work for everyone. Medications can be prohibitively expensive these days, and may cost significantly more than the injured party can afford to cover upfront. Also, waiting for that reimbursement is an unpredictable process. Some insurance companies can take a very long time to process reimbursement payments.
There is the option of pursuing prescription refills through a mail order pharmacy company. Some of these companies will send medications that your doctors have prescribed, and may not require preapproval. One pharmacy that does this is the Injured Workers Pharmacy, based in Methuen, Massachusetts. In most cases, this pharmacy company will provide the medication to you and await later payment from your insurance companies. The Injured Workers Pharmacy takes a risk in trusting that your insurance company will make good on their reimbursement.
The BWC has specific regulations for all aspects of workers’ compensation procedures. If you are unfamiliar with the process of filing a claim, it can seem complicated. Having the guidance of an experienced workers’ compensation lawyer can help you receive reimbursements as soon as possible and avoid unnecessary medical expenses.