As soon as an injury occurs, it should be reported to the Ohio Bureau of Workers’ Compensation (BWC) either online or by calling 1-800-644-6292. Reporting initiates a claim and generates a BWC claim number, which is essential for obtaining medical and pharmacy benefits. Present this claim number to the treating provider and pharmacy.
When can I receive medications related to the injury?
For state-fund claims, BWC allows the first fill of select medications to be dispensed prior to an initial claim determination. This helps ensure immediate treatment following a workplace injury.
How is prescription medication paid for under workers’ compensation?
- State-Fund Claims: Medications are processed through BWC’s Pharmacy Benefits Manager (PBM), (currently) Navitus. The pharmacy submits the claim electronically at the point of sale, and Navitus processes and pays the bill directly.
- Self-Insured Claims: These claims are not processed through BWC’s pharmacy program. Instead, you must work directly with your employer or their third-party administrator (TPA) for authorization and reimbursement of prescription medication.
What if I’m unsure whether my claim is state-fund or self-insured?
You can confirm your claim type by contacting your Managed Care Organization (MCO) at 1-800-644-6292 or reviewing your BWC claim documents.
What should I provide to the pharmacy?
Give the pharmacy your BWC claim number and explain that the injury is work-related. The pharmacy will then verify coverage and bill Navitus directly for state-fund claims. For self-insured claims, the pharmacy may need prior approval or a billing arrangement through the employer or TPA.
What if there is a dispute or problem with my self-insured employer regarding medication coverage?
You must first attempt to resolve the issue directly with the self-insured employer or their designated TPA. If you encounter difficulties, you may contact the BWC Self-Insured Department at 614-466-8222 or email [email protected]. However, this department does not manage individual claims—its role is to assist in resolving compliance or systemic issues when direct employer resolution fails.
What is the outpatient drug formulary?
BWC has a defined Outpatient Medication Formulary under Ohio Administrative Code, which outlines approved medications for treatment of allowed conditions in state-fund claims. The PBM uses this formulary to approve or deny medications.
Are all medications automatically covered?
No. Medications must be:
- Related to the allowed condition(s) in your claim.
- Included in the BWC formulary.
- Approved through prior authorization if required.
If a prescription is denied, your provider may submit additional documentation or request an exception.
What about opioid prescriptions?
Opioid medications are tightly regulated under BWC’s Opioid Prescribing Guidelines. Prescribing providers must follow these rules to ensure the safety and medical necessity of opioid use.
How do I locate a participating pharmacy?
Use BWC’s Pharmacy Locator Tool on their website or call Navitus at 1-844-268-9789 to find in-network pharmacies that can process workers’ compensation claims.
Who do I contact with questions about my prescriptions or claim?
- Pharmacy Benefits (State-Fund Claims):
- BWC Pharmacy Department: 1-877-543-6446 or [email protected]
- Navitus PBM (Pharmacy Inquiries): 1-844-268-9789
- Managed Care Organization (MCO):
- General questions and provider assistance: 1-800-644-6292
- Self-Insured Department (for systemic employer-related issues only):
- Phone: 614-466-8222
- Email: [email protected]
- General Provider Engagement: [email protected]
If you have questions about your workers' compensation benefits, we encourage you to contact the Justice Law Firm today to learn more about how we can help you obtain the benefits you deserve. We welcome your call at 614-543-1320, or we invite you to complete our online contact form at any time.