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The form specifies items such as claimant identity and address, employer name and mailing address, date of injury, claim number, pharmacy identifiers, prescription dates, prescribing physician and DEA number, prescription number, billing unit, national drug code, drug description, generic status, quantity, estimated days supply, refill status, amount paid, and brand name justification using accepted DAW codes. It also includes remarks and provider address, requires receipts to be attached, and provides submission timing and reimbursement policies.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":21,"@type":70,"position":76},"https://docshare.wps.com/template/invoices/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/pharmacy-invoice-instructions/336059/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/pharmacy-invoice-instructions/336059.png","ImageObject",442,249,{"name":88,"@type":89},"Mia  ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-17","2026-09-21",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information must be completed for the claimant and employer sections?","Question",{"text":109,"@type":110},"Enter the claimant’s full name and mailing address, Social Security number, date of injury, and claim number. Provide the employer’s business name and full mailing address based on the employer listed for the injury date or last exposure.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What prescription billing details are required on the form?",{"text":114,"@type":110},"Provide prescription written and filled dates, prescribing physician name and DEA number, prescription number, billing unit (each/ML/GM), national drug code (11 digits with leading zeros when needed), drug name, whether it is generic, drug quantity, estimated days supply, refill status, amount paid, and brand name justification DAW code.",{"name":116,"@type":107,"acceptedAnswer":117},"What submission requirements and reimbursement limitations apply?",{"text":118,"@type":110},"MUST have receipts attached. Submit all pharmacy invoices within 30 days from the date of service. BrickStreet Insurance does not reimburse insurance co-payments.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},336059,1790483766,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":20,"category_name":21,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},687207024478,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","| BI-401\u003Cbr>|  | 01/15 |  |  |\n| --- | --- | --- | --- | --- |\n|  |  | Pharmacy Invoice |  | BrickStreet Insurance\u003Cbr>P.O. Box 3151 Charleston, WV 25332 |\n|  | 1. Claimant’s Name (Last, First and Middle) |  | 2. Claimant’s Address (Street or P.O. Box, City, State, Zip) |  |\n|  | 3. Employer’s Business Name |  | 4. Employer’s Mailing Address |  |\n|  | 5. Claimant’s Social Security Number |  | 6. Date of Injury | 7. Claim Number |\n|  | 8. Name of Pharmacy |  | 9. NABP No. | 10. Check here if payment is to be made to claimant  |\n\n\n| \u003Cbr>PRESCRIPTION DETAIL | 11. Date Written | 12. Date Filled |  | 13. Prescribing Physician |  |  |  |  |  |  |  | 14. Prescribing Physician’s DEA No. |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | 15. Prescription No. | 16. Billing Unit (please check one)\u003Cbr> Each  ML  GM |  | 17. National Drug Code (11 digits) |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | 18. Drug Name | 19. Generic  Yes  No |  | 20. Drug Quantity |  |  |  |  |  | 21. Est. Days Supply |  |  |  |  |  |  |\n|  | 22. Refill  Yes  No | 23. Amount Paid |  | 24. Brand Name Justification (DAW Code from Pharmacist) |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | 25. Pharmacy Phone Number (include area code) |  | 26. Claimant’s Signature Date |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | 27. Pharmacist’s Signature Date |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | 11A. Date Written | 12A. Date Filled |  | 13A. Prescribing Physician |  |  |  |  |  |  |  | 14A. Prescribing Physician’s DEA No. |  |  |  |  |\n|  | 15A. Prescription No. | 16A. Billing Unit (please check one)\u003Cbr> Each  ML  GM |  | 17A. National Drug Code (11 digits) |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | 18A. Drug Name | 19A. Generic  Yes  No |  | 20A. Drug Quantity |  |  |  |  |  | 21A. Est. Days Supply |  |  |  |  |  |  |\n|  | 22A. Refill  Yes  No | 23A. Amount Paid |  | 24A. Brand Name Justification (DAW Code from Pharmacist) |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | 25A. Pharmacy Phone Number (include area code) |  | 26A. Claimant’s Signature Date |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | 27A. Pharmacist’s Signature Date |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\nAs provided by statues, this is to certify that the medication(s) was provided as outlined above and that no other or additional charge for such medication(s) has been or will be made against any person, firm or corporation.  \n\n|  | 28. Remarks | 29. Provider Name and Address |\n| --- | --- | --- |\n\nMUST HAVE RECEIPTS ATTACHED  \nALL PHARMACY INVOICES SHOULD BE SUBMITTED WITHIN 30 DAYS FROM THE DATE OF SERVICE BRICKSTREET INSURANCE DOES NOT REIMBURSE INSURANCE CO-PAYMENTS  \nBrickStreet Mutual Insurance 􀂊 NorthStone Insurance 􀂊 PinnaclePoint Insurance 􀂊 SummitPoint Insurance  \nINSTRUCTIONS FOR COMPLETING PHARMACY INVOICE BI-401  \n1. CLAIMANT NAME: Enter the full name, last name, first name, and middle initial, with the spelling exactly as it appears on your compensability approval letter or social security card.  \n2. CLAIMANT ADDRESS: Enter your full mailing address including street number, post office box or rural route number, city, state and zip code.  \n3. EMPLOYER BUSINESS NAME: Enter the name of the employer for which you were working on the date of injury or date of last exposure. (“Last exposure” applies only to those claimants suffering from an occupational disease. )  \n4. EMPLOYER MAILING ADDRESS: Enter the full address for the employer listed in Item 3.  \n5. CLAIMANT SOCIAL SECURITY NUMBER: Enter social security number.  \n6. DATE OF INJURY: Enter the official date of injury or last exposure as listed on the compensability approval letter.  \n7. CLAIM NUMBER: Enter the claim number assigned by BrickStreet to the injury claim. This number is found on the compensability approval letter or claimant ID card.  \n8. NAME OF PHARMAC","cbCaig4BsZHGdOJe","https://ap.wps.com/l/cbCaig4BsZHGdOJe","pdf",291258,"English","# Pharmacy Invoice BI-401\n## Form fields (claimant, employer, pharmacy, prescription)\n## Prescription detail items and coding\n## Submission requirements and reimbursement notes\n## Instructions for completing the pharmacy invoice","[{\"question\":\"What information must be completed for the claimant and employer sections?\",\"answer\":\"Enter the claimant’s full name and mailing address, Social Security number, date of injury, and claim number. Provide the employer’s business name and full mailing address based on the employer listed for the injury date or last exposure.\"},{\"question\":\"What prescription billing details are required on the form?\",\"answer\":\"Provide prescription written and filled dates, prescribing physician name and DEA number, prescription number, billing unit (each/ML/GM), national drug code (11 digits with leading zeros when needed), drug name, whether it is generic, drug quantity, estimated days supply, refill status, amount paid, and brand name justification DAW code.\"},{\"question\":\"What submission requirements and reimbursement limitations apply?\",\"answer\":\"MUST have receipts attached. Submit all pharmacy invoices within 30 days from the date of service. BrickStreet Insurance does not reimburse insurance co-payments.\"}]","Pharmacy Invoice - Instructions | PDF",1790013429]