Pharmacy providers must submit bills for outpatient medications at the point-of-service in all claims. To submit a bill at the point-of-service, the pharmacy must transmit at least two of the following three items, along with the other billing information, to the pharmacy benefit manager (PBM):
• Cardholder ID (Social Security number).
• Claim/reference ID (BWC claim number including hyphen).
• Date of injury.
Other billing information:
• BIN: 012592
• PCN: OHBWC
• Group: none
The PBM verifies the information, processes the bill, and sends the pharmacy an appropriate message based on the claim’s status, allowed conditions, and formulary coverage and restrictions. The PBM pays pharmacy provider bills according to the pricing detailed below.
Ohio BWC Payer Sheet, B1-B3 Transactions.
First Fill Program
BWC established a program to provide reimbursement for the first fill of prescription drugs for medical conditions identified in a pending workers’ compensation claim, including for situations prior to a BWC claim number being assigned. The program is limited to the first fill of prescription drugs that occur prior to the date BWC issues an initial claim determination order. The pharmacy must submit two of the three items, along with the other billing information, as above. Additionally, the pharmacy must submit:
• ‘444000000’ in the Prior authorization number submitted field (NCPDP 462-EV).
• PA type code ‘02’ (NCPDP 461-EU).
Prescription reimbursement is subject to the following limitations:
• The quantity limits listed in the First Fill appendix without refills.
• One drug per therapeutic drug class listed in the First Fill appendix (except antiretrovirals, antivirals, and antibiotics).
• Extemporaneous compounded prescriptions are not eligible for reimbursement under the first fill program.
• Drugs listed in the full Formulary appendix but not in the First Fill appendix are not eligible for reimbursement unless prior authorization was approved by BWC.
The prescribing physician must indicate the prescription is for a work-related injury. A pharmacist or pharmacy intern who receives a telephone prescription may also write and sign that it is work related on the prescription. The pharmacy provider is guaranteed payment for drugs listed on the first fill formulary, so long as the first fill program requirements are followed, regardless of final claim acceptance or denial.
First fill prescriptions are reimbursed in the same manner as other prescriptions. Custom messaging will direct the pharmacy provider to resubmit the prescription after consulting the First Fill appendix to ensure coverage.
Generic drug requirement
BWC does not reimburse for brand name drugs when a generic equivalent is widely available. This rule applies to all claims, regardless of date of injury. If a brand name drug is requested and dispensed, the injured worker pays the difference in price between the generic price and the brand name drug.
Injured worker outpatient medication reimbursement
If the injured worker paid for prescribed outpatient medication to treat an allowed work-related injury, they can request reimbursement using the C-17 Request for Injured Worker Outpatient Medication Reimbursement form. Use of this form should be limited to prescriptions that were paid when the injury claim is not allowed or payment denied.
Durable medical equipment; disposable medical supplies; and home infusion therapy
MCOs determine reimbursement eligibility for these services that may be obtained in a pharmacy: Contact the MCO for specific requirements for the use of the Service Invoice (C-19) or HCFA 1500.
The Ohio Bureau of Workers’ Compensation (BWC) utilizes a Maximum Allowable Cost (MAC) pricing program for pharmacy reimbursement. The MAC program aligns the incentives for the pharmacy, injured worker, and the BWC program.
BWC is committed to ensuring that MAC pricing allows for pharmacy profitability while ensuring the cost-effective use of program funds. For all generic products, the objective is for the pharmacy to make equivalent or greater gross profit percentage per prescription as compared to the equivalent brand product.
The program’s funds will be used to continue providing quality prescription coverage to Ohio’s injured workers. The MAC prices will maintain reasonable profitability incentives to dispense generic products over brand products.
Drug shortages and pricing inquires
Drug shortage information is verified through the FDA website. In addition, if you feel a product is in short supply or unavailable; please fax the information to BWC using the MAC Price Inquiry form.
Use the MAC Price Inquiry form to provide feedback for both MAC pricing and multiple source generic product availability. BWC will research concerns in accordance with Ohio Revised Code 3959.111.
Exception process to update MAC list
The MAC list will be reviewed with ongoing adjustments based upon market changes in pricing and product availability. BWC and the PBM will work jointly to review items where profitability is questioned. For further questions concerning the MAC list, please contact BWC at 1-877-543-6446.