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OhioBWC - Provider - Service:  Forms

Forms for pharmacy benefits

Request for Prior Authorization of Medication (MEDCO-31) — Physicians use this form to request prior authorization for medications not typically used for industrial injuries or occupational diseases. Fax completed MEDCO-31 forms to SXC Health Solutions’s prior authorization fax number, which is located at the bottom of the form.

Formulary Medication Request Form (MEDCO-35) - Physicians use this form to ask the Pharmacy & Therapeutics Committee to consider adding a particular drug to the formulary.

Outpatient Medication Invoice (C-17) — Injured workers should use this form to request payment for prescribed outpatient medication only. Since pharmacy providers are expected to submit bills directly to BWC’s pharmacy benefits manager (PBM) electronically, the use of the C-17 should be rare.
Note: Injured workers whose employers are self-insuring should contact their employers for instructions on billing for outpatient medications. SXC Health Solutions is not responsible for processing bills in self-insuring claims.

Service Invoice (C-19) or HCFA 1500 — MCOs determine reimbursement eligibility for the following services that may be obtained in a pharmacy: durable medical equipment; disposable medical supplies; and home infusion therapy. Drugs supplied in a physician’s office will not be reimbursed as outpatient medication. Contact the MCO for specific requirements for the use of the C-19 and HCFA 1500.



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