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 ACS State Healthcare’s prior authorization fax number, which is located at the bottom of the form.

Request for Prior Authorization of Non-Preferred Medication (MEDCO-32) — Physicians use this form to request prior authorization for medications on BWC’s non-preferred drug list. Some medications in the following categories require prior authorization: non-steroidal anti-inflammatory drugs (NSAIDs); Cox-2 inhibitors; skeletal muscle relaxants; and opioid analgesics. Fax completed MEDCO-32 forms to ACS State Healthcare’s prior authorization fax number, which is located at the bottom of the form.

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. ACS State Healthcare 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.