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Good Afternoon
4:32:11 PM CDT
Thursday, April 24, 2014

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Pharmacy Benefit Management

Topics First Fill Program Forms & Publications Service Guide for Pharmacists
Pharmacy Overview Sign Up Process Prior Authorization Form (M3) Quick Reference Sheet
US Script Pharmacy Fee Schedule Formulary/Product Resrictions Brand Medication Prior Authorization Form (P2)
Plan Benefits Generic Dispensing Drug Quantity Limits Relistor Prior Authorization Form (P3)
Plan Design First Fill Product Restrictions DAW1 Policy Statement
    Sample Narcotic Contract  

Plan Design

  • Days Supply Limits
    • Supplies will be limited to 34 days for acute and 60 days for chronic medication
  • Drug Quantity Limits
  • Formulary/Product Restrictions
    • Medication generally excluded from coverage; however, on specific cases approval may be given. Prior authorization is required by the pharmacy director.
    • For a complete list of restricted medications go to Formulary/Product Restrictions
  • Charges for Durable Medical Equipment (DME) or supply items (i.e. gauze, tape etc.) need to be submitted to WSI in paper format or electronically in the CMS 1500 format.
  • Generic dispensing requirements (generic medication must be dispensed)

If prescribing a medication on the restricted list, prior authorization is required. This process can be initiated in two ways:

  • Physician ordering the script can complete and submit the M3 form
  • Pharmacist attempting to fill the script can call WSI

The Service Guide for Pharmacists outlines when to contact US Script and when to contact WSI. The Pharmacy Program Quick Reference Sheet provides further explanation about the online messages the pharmacy receives at the point-of-sale.

Contact Information: Harvey Hanel PharmD
Pharmacy Director
Workforce Safety & Insurance
1-800-440-3796 ext 87222#
Fax 1-701-328-3793

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