Sedgwick Claims Kit Pennsylvania

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1 Sedgwick Claims Kit Pennsylvania P.O. Box Lexington, KY Toll Free: Fax:

2 Dear Insured: We would like to welcome you as a policyholder of Southern Insurance Company. Sedgwick is your Claims Administrator and we are pleased to be able to provide you with workers compensation claims handling services. Please follow the below instructions for filing a new claim and note the claim kit attachment. Where do I report a claim? Phone: (855-7ATLAS7) OR; OR: Fax: Where do I send my injured employee for medical treatment? Website: Sedgwick Claim Kit Attachments: Employer Posting Notice (LIBC-500) Atlas General First Fill Temporary Pharmacy Card Atlas General Pharmacy Card Need a loss run? us: Have more questions? Contact the Atlas Customer Care Team at Sedgwick - One of our friendly Client Services Associates will be happy to assist you. Phone: We appreciate your business and believe that communication is critical for successful claims administration. We encourage you to contact us if you have any questions. PENNSYLVANIA Welcome Letter Southern Insurance Co. 7/2014

3 REMEMBER: It is Important to Tell Your Employer about Your Injury The name, address and telephone number of your employer s workers compensation insurance company, third-party administrator (TPA), or person handling workers compensation claims for your company, are shown below. Employer Name: IF INSURED: (Complete all applicable spaces) Name of Insurance Company: Date Posted: IF SOMEONE OTHER THAN INSURER IS HANDLING CLAIMS: (Complete all applicable spaces) Name of TPA (Claims administrator): Address: Address: Telephone Number: Telephone Number: Insurer s Bureau Code: IF SELF-INSURED: (Complete all applicable spaces) Name of person handling claims at the self-insured: IF SOMEONE OTHER THAN SELF-INSURER IS HANDLING CLAIMS: (Complete all applicable spaces) Name of TPA (Claims administrator): Address: Address: Telephone Number: Telephone Number: Self-Insured Bureau Code: Department of Labor & Industry Bureau of Workers Compensation 1171 S. Cameron Street, Room 103 Harrisburg, PA LIBC-500 REV 5-09 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program

4 First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: Print this page immediately upon receiving notice of injury, fill in the information below and give it to your employee. Injured Employee: 1. If you need a prescription filled for a work-related injury or illness, go to a Tmesys network pharmacy. 2. Give this page to the pharmacist. 3. The pharmacist will fill your prescription at no cost. CARRIER/TPA Sedgwick INJURED WORKER NAME SOCIAL SECURITY NUMBER Please provide directly to Pharmacist EMPLOYER/OTHER ENTITY Atlas General Insurance DATE OF INJURY Notice to Cardholder: This card should be presented to your pharmacy to receive medication for your work-related injury. It is only valid within 30 days of your date of injury. For information regarding the program or to find nearby pharmacies call Attention Pharmacists: Call to establish First Fill benefit eligibility and obtain the ID# for online adjudication of approved benefits for the injured worker. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information listed above. 3. The Help Desk will provide an ID number for adjudication. (To create a card for your wallet, cut along outer line and fold in half.) Finding a Network Pharmacy Use one of these easy methods to find a network pharmacy: Visit one of the following pharmacy chains: Walgreens Rite Aid Walmart CVS Duane Reade Kroger Publix Safeway Use our pharmacy locator online: Call us: PMSI, Inc. All rights reserved. C1257B SCMS.

5 Tmesys Retail Pharmacy Network* More than 60,000 pharmacies, including large chains and many neighborhood independent pharmacies, meaning that your prescription can be filled at most pharmacies nationwide. Accredo Health Group Anchor Pharmacy Arrow Prescription Center Aurora Pharmacy Baker s Pharmacy Bartell Drugs Bashas United Drug Bel Air Pharmacy Big Y Pharmacy Biggs Pharmacy Bi-Lo Bi-Mart Bioscrip Pharmacy BJ s Pharmacy Brookshire s Pharmacy Bruno s Pharmacy Buehler s Pharmacy Caremark Pharmacy Carle Rx Express Carrs Quality Center City Market Pharmacy Clinic Pharmacy Coborn s/cash Wise Concord Drugs Costco Pharmacy Cub Pharmacy CVS Pharmacy D&W Pharmacy Dahl s Pharmacy Dierbergs Dillon Pharmacy Discount Drug Mart Doc s Drug Dominick s Finer Foods Drug Emporium Drug Mart Drug Town Drug Warehouse Drugs For Less E. W. James Pharmacy Eagle Pharmacy Eaton Apothecary Econofoods Pharmacy Edwards Pharmacy Fagen Pharmacy Family Drug Store Family Fare Pharmacy Family Pharmacy Familymeds Pharmacy Farm Fresh Pharmacy Farmer Jack Pharmacy Food 4 Less Pharmacy Food City Pharmacy Food Lion Pharmacy Food Town Pharmacy Food World Pharmacy Fred Meyer Pharmacy Fred s Pharmacy Fruth Pharmacy Fry s Pharmacy Gemmel Pharmacy Gentiva Health Services Genuardi s Pharmacy Gerbes Pharmacy Giant Eagle Pharmacy Giant Pharmacy Glen s Pharmacy Good Day Pharmacy Grand Union Pharmacy Gristedes Pharmacy H-E-B Pharmacy Haggen Foods Hannaford Happy Harry s Harmons Pharmacy Harps Pharmacy Harris Teeter Hartig Drug Harvest Foods Pharmacy Harveys Supermarket Pharmacy Hen House Pharmacy Hi-School Pharmacy Homeland Pharmacy Hometown Pharmacy Hy-Vee Pharmacy Ingles Pharmacy Kmart Pharmacy Kerr Drug King Kullen Pharmacy King Soopers Pharmacy Kings Pharmacy Kinney Drugs Klingensmith s Knight Drugs Kohl s Pharmacy Kohll s Pharmacy Kopp Drug Kroger Pharmacy Lewis Pharmacy Lifechek Drug Longs Drug Louis and Clark Lowes Marketplace Marc s Pharmacy Marsh Drugs Martin s Pharmacy May s Drug Store Med-Fast Pharmacy Medical Arts Pharmacy Medicap Pharmacy Medicine Shoppe Pharmacy (various) Med-X Drug Meijer Pharmacy Minyard Pharmacy Morton Pharmacy Mr. Discount Drugs Navarro Discount Pharmacies NeighborCare Pharmacy No Frills Pharmacy Network Pharmacy Owens Pharmacy P&C Food & Pharmacy Pamida Pharmacy Park Nicollet Pharmacy Pathmark Pharmacy Pavilions Pharmacy PharmaCare Pharmacy Pharmacy Express Pharmacy Plus Pick N Save Pharmacy Piggly Wiggly PrairieStone Pharmacy Price Chopper Pharmacy Price Cutter Pharmacy Publix Pharmacy Q Pharmacy QFC Pharmacy Quality Markets Pharmacy QuickChek Pharmacy QVL Pharmacy Rainbow Pharmacy Raley s Drug Center Ralphs Pharmacy Randalls Pharmacy Reasors Pharmacy Rite Aid Pharmacy Ritzman Natural Health Rosauers Pharmacy RXD Pharmacy Sack n Save Pharmacy Safeway Pharmacy Sam s Pharmacy Save Mart Pharmacy Save-Rite Pharmacy Schnucks Pharmacy Scolaris Pharmacy Sedanos Pharmacy & Discount Shaw s Pharmacy Shaws/Osco Pharmacy Shop n Save Pharmacy Shopko Pharmacy Shoppers Pharmacy ShopRite Pharmacy Snyder Drug Emporium Southern Family Market Star Pharmacy Stop & Shop Pharmacy Sunscript Pharmacy Super 1 Pharmacy Super D Super G Super Foodmart Pharmacy Super Fresh Pharmacy Super Rx Pharmacy Sweetbay The Pharm Thriftway Drugs Thrifty White Drug Times Pharmacy Tom Thumb Pharmacy Tops Pharmacy U-Save Pharmacy Ukrops Pharmacy United Pharmacy USA Drug Vix Pharmacy Vons Pharmacy VG s Pharmacy Waldbaum s Pharmacy Walgreens Wal-Mart Pharmacy Wegman Pharmacy Weis Pharmacy White Drug Winn-Dixie Yokes Pharmacy *List subject to change. This is a partial listing only PMSI, Inc. All rights reserved. C1257B SCMS

6 Tarjeta temporal para surtir por primera vez sus recetas en farmacias Facilita la tarea de surtir las recetas correspondientes a la compensación por accidentes o enfermedades laborales. Empleador: Imprima esta página inmediatamente después de recibir un aviso de lesión, complete la información que se encuentra a continuación y entréguesela a su empleado. Empleado lesionado: 1. Si necesita que se le surta una receta por una lesión o enfermedad relacionada con el trabajo, diríjase a una farmacia de la red Tmesys. 2. Entréguele esta página al farmacéutico. 3. El farmacéutico le surtirá la receta sin costo alguno. COMPAÑÑÍA DE SEGUROS/ADMINISTRADOR EXTERNO (TPA) Sedgwick NOMBRE DEL EMPLEADO LESIONADO EMPLEADOR/OTRA ENTIDAD Atlas General Insurance At. farmacéuticos: Llamen al a fin de establecer la elegibilidad para el beneficio de surtir por primera vez su receta y obtener el número de ID para la adjudicación en línea de los beneficios aprobados para el trabajador lesionado. Tmesys es la administradora de beneficios de farmacia (PBM) asignada a este paciente. NÚMERO DE SEGURO SOCIAL Entregar directamente al farmacéutico FECHA EN QUE OCURRIÓ LA LESIÓN Aviso al titular de la tarjeta: Para recibir los medicamentos correspondiente a la lesión laboral sufrida, debe presentarle esta tarjeta al farmacéutico. Solo es válida durante 30 días a partir de la fecha de la lesión. Para obtener información sobre el programa o para encontrar farmacias cercanas a usted, llame al RxPCN CAL or Envoy Acct. # (Si desea llevar la tarjeta en la billetera, corte a lo largo de la línea exterior y dóblela por la mitad) Farmacéutico: 1. Llame al servicio de asistencia de farmacias de Tmesys al Suministre la información que figura arriba. 3. El servicio de asistencia le dará un número de ID correspondiente a la adjudicación. Cómo encontrar una farmacia de la red Para encontrar una farmacia de la red, use uno de estos sencillos métodos: Visite alguna de las siguientes cadenas de farmacias: Walgreens Walmart Duane Reade Publix Rite Aid CVS Kroger Safeway Use nuestro localizador de farmacias en línea: Llámenos: PMSI, Inc. All rights reserved. C1257B SCMS

7 Red de farmacias minoristas de Tmesys* Más de 65,000 farmacias, entre ellas grandes cadenas, así como farmacias independientes, lo cual permite que le puedan surtir sus recetas en la mayoría de farmacias del país. Accredo Health Group Anchor Pharmacy Arrow Prescription Center Aurora Pharmacy Baker s Pharmacy Bartell Drugs Bashas United Drug Bel Air Pharmacy Big Y Pharmacy Biggs Pharmacy Bi-Lo Bi-Mart Bioscrip Pharmacy BJ s Pharmacy Brookshire s Pharmacy Bruno s Pharmacy Buehler s Pharmacy Caremark Pharmacy Carle Rx Express Carrs Quality Center City Market Pharmacy Clinic Pharmacy Coborn s/cash Wise Concord Drugs Costco Pharmacy Cub Pharmacy CVS Pharmacy D&W Pharmacy Dahl s Pharmacy Dierbergs Dillon Pharmacy Discount Drug Mart Doc s Drug Dominick s Finer Foods Drug Emporium Drug Mart Drug Town Drug Warehouse Drugs For Less E. W. James Pharmacy Eagle Pharmacy Eaton Apothecary Econofoods Pharmacy Edwards Pharmacy Fagen Pharmacy Family Drug Store Family Fare Pharmacy Family Pharmacy Familymeds Pharmacy Farm Fresh Pharmacy Farmer Jack Pharmacy Food 4 Less Pharmacy Food City Pharmacy Food Lion Pharmacy Food Town Pharmacy Food World Pharmacy Fred Meyer Pharmacy Fred s Pharmacy Fruth Pharmacy Fry s Pharmacy Gemmel Pharmacy Gentiva Health Services Genuardi s Pharmacy Gerbes Pharmacy Giant Eagle Pharmacy Giant Pharmacy Glen s Pharmacy Good Day Pharmacy Grand Union Pharmacy Gristedes Pharmacy H-E-B Pharmacy Haggen Foods Hannaford Happy Harry s Harmons Pharmacy Harps Pharmacy Harris Teeter Hartig Drug Harvest Foods Pharmacy Harveys Supermarket Pharmacy Hen House Pharmacy Hi-School Pharmacy Homeland Pharmacy Hometown Pharmacy Hy-Vee Pharmacy Ingles Pharmacy Kmart Pharmacy Kerr Drug King Kullen Pharmacy King Soopers Pharmacy Kings Pharmacy Kinney Drugs Klingensmith s Knight Drugs Kohl s Pharmacy Kohll s Pharmacy Kopp Drug Kroger Pharmacy Lewis Pharmacy Lifechek Drug Longs Drug Louis and Clark Lowes Marketplace Marc s Pharmacy Marsh Drugs Martin s Pharmacy May s Drug Store Med-Fast Pharmacy Medical Arts Pharmacy Medicap Pharmacy Medicine Shoppe Pharmacy (various) Med-X Drug Meijer Pharmacy Minyard Pharmacy Morton Pharmacy Mr. Discount Drugs Navarro Discount Pharmacies NeighborCare Pharmacy No Frills Pharmacy Network Pharmacy Owens Pharmacy P&C Food & Pharmacy Pamida Pharmacy Park Nicollet Pharmacy Pathmark Pharmacy Pavilions Pharmacy PharmaCare Pharmacy Pharmacy Express Pharmacy Plus Pick N Save Pharmacy Piggly Wiggly PrairieStone Pharmacy Price Chopper Pharmacy Price Cutter Pharmacy Publix Pharmacy Q Pharmacy QFC Pharmacy Quality Markets Pharmacy QuickChek Pharmacy QVL Pharmacy Rainbow Pharmacy Raley s Drug Center Ralphs Pharmacy Randalls Pharmacy Reasors Pharmacy Rite Aid Pharmacy Ritzman Natural Health Rosauers Pharmacy RXD Pharmacy Sack n Save Pharmacy Safeway Pharmacy Sam s Pharmacy Save Mart Pharmacy Save-Rite Pharmacy Schnucks Pharmacy Scolaris Pharmacy Sedanos Pharmacy Shaw s Pharmacy Shaws/Osco Pharmacy Shop n Save Pharmacy Shopko Pharmacy Shoppers Pharmacy ShopRite Pharmacy Snyder Drug Emporium Southern Family Market Star Pharmacy Stop & Shop Pharmacy Sunscript Pharmacy Super 1 Pharmacy Super D Super G Super Foodmart Pharmacy Super Fresh Pharmacy Super Rx Pharmacy Sweetbay The Pharm Thriftway Drugs Thrifty White Drug Times Pharmacy Tom Thumb Pharmacy Tops Pharmacy U-Save Pharmacy Ukrops Pharmacy United Pharmacy USA Drug Vix Pharmacy Vons Pharmacy VG s Pharmacy Waldbaum s Pharmacy Walgreens Wal-Mart Pharmacy Wegman Pharmacy Weis Pharmacy White Drug Winn-Dixie Yokes Pharmacy *Lista sujeta a cambios. Ésta es sólo una lista

8 P.O. Box Tampa, FL PERSONAL & CONFIDENTIAL Important Insurance Claim Document Enclosed Questions? DOI «DOI» ID# «subid» Name «Patientname» Carrier «Carrier» DOI «DOI» ID# «subid» Name «Patientname» Carrier «Carrier» Prescription Delivery By Mail Necesitas ayuda en español? Llame al In addition to providing access to your medications at a local pharmacy, Tmesys can also deliver your medications to your home through our PMSI Mail Order program at no cost. Using this convenient program means you will not have to drop off or pick up your prescription or wait in line while it is being lled. For more information or to sign up, call or go to click on Mail Order Overview. RxPCN CAL or Envoy Acct.# Issuer (80840) «DOI» «subid» «Patientname» «Carrier» Injury Date ID# Name Carrier/TPA

9 Attention Pharmacist: Tmesys is the workers compensation PBM for this patient. For questions regarding transmission, call RxPCN CAL or Envoy Acct.# Issuer (80840) Attention Pharmacist: Tmesys is the workers compensation PBM for this patient. For questions regarding transmission, call RxPCN CAL or Envoy Acct.# Issuer (80840) Attention Cardholder: For questions regarding coverage or to nd a pharmacy call Tmesys at: or visit Attention Pharmacist: Tmesys is the designated workers compensation PBM for this patient. Call Tmesys with questions regarding transmission or rejection at: Note: Your use of this card is limited to those prescriptions medically related to an injury that is considered to be covered under the applicable state workers compensation law. IMPORTANT: ONCE CARDS HAVE BEEN REMOVED PLEASE RETAIN THIS PORTION FOR YOUR RECORDS Taking Care of Using the Pharmacy Card We want to make it easy for you to obtain the medication you need to recover from your work-related injury. Just follow these steps: 1. Activate the card by calling the toll-free number. 2. Separate the attached cards and place one in your wallet and one on your key ring. 3. Give a card to the pharmacist next time you have a new prescription or refill. 4. Your prescription will be filled at no cost. Finding a Pharmacy You can use any pharmacy that is part of the Tmesys network to ll your prescription and with over 60,000 locations, the card is accepted at most pharmacies nationwide. Finding a network pharmacy is simple! Use one of the options below: Visit one of the following pharmacy chains: Walgreens Walmart Duane Reade Publix Rite Aid Target Kroger Safeway Go to one of these nearby pharmacies: «Pharmacy1» «Pharmacy2» «Pharmacy3» Look up a pharmacy on the website: click on Pharmacy Locator and choose a search option. Call us toll free at <<PATIENTNAME>> 2011 PMSI, Inc. All Rights Reserved. SCMSMOD

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