Prescribers use this one-page request when a drug for an Ohio workers' compensation claim needs BWC pharmacy prior authorization. It lists up to five medications with strength and the treating diagnosis for each, plus a written justification linking them to the work injury and allowed conditions. The BWC pharmacy department reviews the request with the attached office notes.
The prescriber or an authorized person completes the whole form, including prescriber name, NPI and contact details, the injured worker's claim number, date of injury and date of birth, and signs it.
Download the current version from the source each time; forms change without notice.
Request for Prior Authorization of Medication
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Attach recent office visit notes that support the justification. Opioid requests also need the supporting documentation required by Ohio Adm.Code 4123-6-21, and post-surgical medication requests need proof that the surgery was approved. Missing attachments leave the pharmacy department without the information the form asks for.
The form has five numbered lines, each for a medication name and strength with its own treating diagnosis. One justification section covers all of them, so it should address how each listed drug relates to the allowed conditions in the claim.