Billing L&I for Pharmacy Services

First Fills

L&I will pay pharmacies or reimburse workers for prescription drugs prescribed during the initial visit only.

L&I will not pay:

  • For refills of the initial prescription or any additional prescriptions for the original injury before the claim is accepted.
  • If it is a federal or self-insured claim.
  • If it is prescribed by a provider who has been excluded from the provider network.

Payment for initial prescription drugs shall be based on L&I's fee schedule. Your bill must be received by L&I within one year of the date of service.

Using the point-of-sale (POS) system

To obtain a valid State Fund claim number for billing, you must see a copy of the report of accident (ROA) or the claim ID card. See an example of the ROA with attached ID card (217 KB PDF / 1 min).

When the prescription meets criteria for guaranteed payment, the POS system will send rejection code 52 or 67 with the following information:

  • Maximum allowed amount: $XX.XX and
  • A message: "Prescription qualifies for first fill; submit prior authorization number 46484254557 after verifying claim number from report of accident or claim ID card."

Remember to submit a valid prior authorization qualifier (08) along with the authorization number.

How to identify a State Fund claim

State Fund claim numbers are alpha-numeric, consisting of 7 characters. They begin with B, C, F, G, H, J, K, L, M, N, P, X, or Y followed by 6 digits or double alpha (e.g. AA, AB, AG) followed by 5 digits. See an example on this ROA with attached ID card sample (217 KB PDF / 1 min).

The following table shows the required entries in the Transaction Header Segment of the NCPDP 5.1 specifications.

See RCW 51.36.010 ( for more information.

Transaction Header Segment
Transaction Header Segment
Field name Data element number Required status Valid values/comments
Prior authorization type code 461-EU Optional 08 - Payer defined exemption for use with reject code 52 or 67.
Prior authorization number submitted 462-EV Optional Enter prior auth 46484254557 after verify the claim number from the ROA or claim ID card for initial prescription.
Dispense as written/product selection code 408-D8 Optional Valid values:
0=No product selection indicated (substitution permitted)
1=Substitution not allowed by prescriber (DAW)
6=Override for emergency supply of drug requiring prior authorization.

Refill(s) and/or additional prescription dispensed before claim acceptance

  • You may charge the injured worker for the prescription and submit the bill with the amount paid in the patient paid amount or co-pay field. L&I will capture the bill and reimburse the injured worker if and when the claim is allowed.
  • You may submit a paper bill. L&I will suspend the bill and reimburse you when the claim is allowed.
  • You may wait until the claim is allowed and then submit it through the POS system.

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