Sedgwick Claims Kit South Carolina

Transcription

1 Sedgwick Claims Kit South Carolina 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) AtlasGeneralInsurance@sedgwickcms.com Fax: Where do I send my injured employee for medical treatment? Website: Sedgwick Claim Kit Attachments: Workers Compensation Compliance Poster Employer s First Report of Injury Form (WCC-12A) Wage Statement (WCC-20) Atlas General First Fill Temporary Pharmacy Card Atlas General Pharmacy Card Need a loss run? us: Lossruns@atlas.us.com 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: AtlasTeam@Sedgwickcms.com 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. SOUTH CAROLINA Welcome Letter Southern Insurance Co. 7/2014

3 South Carolina Workers Compensation February 20, 2014 Workers Compensation Compliance Poster We are operating under and subject to the South Carolina Workers Compensation Act In case of accidental injury or death to an employee, the injured employee, or someone acting in his or her behalf, must give immediate notice to the employer or general authorized agent. Failure to give such immediate notice may be the cause of serious delay in the payment of compensation to the injured employee or his or her dependents and may result in failure to receive any compensation benefits under the law. Workers Compensation: 1. Pays 100% of your medical bills and some other expenses. 2. Compensates you for 66 2/3% of your salary, limited to the maximum wage set by law, if you are unable to work for more than seven (7) calendar days. If you are injured on the job, you should: 1. Notify your employer at once. You cannot receive benefits unless your employer knows you are injured. 2. Tell the doctor your employer sends you that you are covered by workers compensation. 3. Notify the Workers Compensation Provider listed on this poster or the South Carolina Workers Compensation Commission at if you experience undue delays or problems with your claim. South Carolina Workers Compensation Commission P.O. Box 1715,1333 Main Street, Suite 500 Columbia, S.C Workers Compensation Provider Name Mailing Address Claims Telephone Number

4 EMPLOYER (NAME & ADDRESS INCL ZIP) S.C. WORKERS COMPENSATION COMMISSION FIRST REPORT OF INJURY OR ILLNESS CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA LOG NUMBER REPORT PURPOSE CODE JURISDICTION JURISDICTION CLAIM NUMBER INSURED REPORT NUMBER EMPLOYER S LOCATION ADDRESS (IF DIFFERENT) LOCATION # INDUSTRY CODE EMPLOYER FEIN PHONE # CARRIER/CLAIMS ADMINISTRATOR CARRIER (NAME, ADDRESS, & PHONE #) POLICY PERIOD CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO) TO CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN AGENT NAME & CODE NUMBER EMPLOYEE/WAGE NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE ADDRESS (INCL ZIP) SEX MARITAL STATUS OCCUPATION/JOB TITLE Male Female Unknown Unmarried/Single/Divorced Married Separated EMPLOYMENT STATUS Unknown NCCI CLASS CODE PHONE # OF DEPENDENTS RATE PER: DAY MONTH DAYS WORKED/WEEK WEEK OTHER: FULL PAY FOR DAY OF INJURY? YES NO DID SALARY CONTINUE? YES NO OCCURRENCE/TREATMENT TIME EMPLOYEE BEGAN WORK AM DATE OF INJURY/ILLNESS TIME OF OCCURRENCE AM LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN PM ( ) CANNOT BE DETERMINED PM CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER S PREMISES? TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? YES NO WERE THEY USED? YES PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS) INITIAL TREATMENT NO OTHER WITNESSES (NAME & PHONE #) 0 NO MEDICAL TREATMENT 1 MINOR: BY EMPLOYER 2 MINOR CLINIC/HOSP 3 EMERGENCY CARE 4 HOSPITALIZED > 24 HOURS FUTURE MAJOR MEDICAL/ LOST TIME 5 ANTICIPATED DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER S NAME & TITLE PHONE NUMBER WCC FORM 12A REV. DATE 04/06 SEE INSTRUCTIONS FOR IMPORTANT INFORMATION REPRINTED WITH PERMISSION OF IAIABC

5 South Carolina Workers Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC EMPLOYER S INSTRUCTIONS DO NOT ENTER DATA IN SHADED FIELDS DATES: Enter all dates in MM/DD/YYYY format. INDUSTRY CODE: This is the code which represents the nature of the employer s business, which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System, published by the Federal Office of Management and Budget. CARRIER: The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant. CLAIMS ADMINISTRATOR: Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim. AGENT NAME & CODE NUMBER: Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy. OCCUPATION/JOB TITLE: This is the primary occupation of the claimant at the time of the accident or exposure. EMPLOYMENT STATUS: Indicate the employee s work status. The valid choices are: Full-Time On Strike Unknown Volunteer Part-Time Disabled Apprenticeship Full-Time Seasonal Not Employed Retired Apprenticeship Part-Time Piece Worker DATE DISABILITY BEGAN: The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise designated by statute. CONTACT NAME/PHONE NUMBER: Enter the name of the individual at the employer s premises to be contacted for additional information. TYPE OF INJURY/ILLNESS: Briefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm). PART OF BODY AFFECTED: Indicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back). DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (e.g. Maintenance Department or Client s office at 452 Monroe St., Washington, DC 26210) If the accident or illness exposure did not occur on the employer s premises, enter address or location. Be specific. WCC FORM 12A REV. DATE 04/06

6 South Carolina Workers Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC EMPLOYER S INSTRUCTIONS cont d ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (e.g. Acetylene cutting torch, metal plate) List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator s scaffolding, electric sander, paintbrush, and paint. Enter NA for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee s injury or illness. SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED: (e.g. Cutting metal plate for flooring) Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting. WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED: Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter NA for not applicable if employee was not engaged in a work process (e.g. walking along a hallway). HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL: (Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.) Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker s right wrist was broken in the fall. DATE RETURN(ED) TO WORK: Enter the date following to most recent disability period on which the employee returned to work. WCC FORM 12A REV. DATE 04/06

7 South Carolina Workers Compensation Commission 1612 Marion Street P.O. Box 1715 Columbia, SC (803) WCC File # Carrier File #: Carrier Code #: 1039 Employer FEIN #: Claimant s Name SSN: Employer s Name Address City, State, Zip Address City, State, Zip Home Phone: Work Phone ( Insurance Carrier Preparer s Name Law Firm Preparer s Phone Date of injury: A. Total Wages Paid 1. Check Applicable Method: Report of earnings of injured employee based on four completed quarters. Report of earnings of injured employee who did not complete four quarters based on actual time worked. Report of earnings of similar employee. Injured employee did not work sufficient time before alleged injury. Hire Date: Report of earnings of injured employee based on alternative method because Form 20 results in a compensation (m/d/yyyy) rate that is not fair and just. (Attach documentation to show how average weekly wage and compensation rate were calculated.) 2. List total wages paid as reported to Employment Security Commission on the Employer Quarterly Contribution and Wage Reports during the four quarters immediately preceding the quarter in which the injury occurred. Do not include the quarter during which the injury occurred. (m/d/yyyy) Quarter Ending Date (m/d/yyyy) 1 st $ 2 nd $ 3 rd $ Total Wages Paid 4 th $ Total Paid List total value of other allowances of any character made in lieu of wages during four quarters above Add lines 2 and 3. TOTAL WAGES PAID List total number of weeks paid to employee during the four quarters immediately preceding the quarter in which the injury occurred. 5. B. Average Weekly Wage 6. To calculate average weekly wage, divide total wages (line 4) by total weeks paid (line 5). AVERAGE WEEKLY WAGE 6. C. Compensation Rate 7. The general rule for calculating the compensation rate is to multiply average weekly wage (line 6) by Estimate compensation rate by multiplying average weekly wage (line 6) by See part 8 below to determine the actual compensation rate The compensation rate is as follows (choose one): The calculated compensation rate (line 7) applies. Enter amount from line 7 on line 8. When average weekly wage (line 6) is less then $75.00, the compensation rate is the average weekly wage. Enter average weekly wage on line 8. When the estimated compensation rate (line 7) is less than $75.00 and average weekly wage (line 6) is more than $75.00, the compensation rate is $ Enter $75.00 on line 8. When the estimated compensation rate (line 7) is more than the maximum compensation rate for the year in which the injury occurred, enter the maximum compensation rate for the year in which the injury occurred on line 8. Employee is within the exceptions listed in S.C. Code Ann. Section List applicable exception here and enter appropriate compensation rate on line 8. WEEKLY COMPENSATION RATE 8. Employees representative shall prepare a Form 20 and serve per R a copy on the claimant within thirty days of beginning temporary compensation. See R when no temporary compensation is paid. NOTE: Average weekly wage represents average gross pay before taxes and other deduction. WHEN THE CLAIMANT DOES NOT AGREE WITH THE COMPENSATION RATE ONLINE 8, HE OR SHE SHOULD CONTACT THE EMPLOYER S REPRESENTATIVE TO TRY TO REACH AN AGREEMENT AS TO THE COMPENSATION RATE. IF NO AGREEMENT CAN BE REACHED THE CLAIMANT SHOULD CONTACT THE CLAIMS DEPARTMENT AT (803) WCC Form # 20 Rev. Date 3/97 20 STATEMENT OF EARNINGS OF INJURED EMPLOYEE

8 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. Prescription Card 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 NDC Envoy RxBin or 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.

9 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

10 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. Prescription Card 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 NDC Envoy RxBin or 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

11 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

12 P.O. Box Tampa, FL PERSONAL & CONFIDENTIAL Important Insurance Claim Document Enclosed Questions? Prescription Card DOI «DOI» ID# «subid» Name «Patientname» Carrier «Carrier» Prescription Card 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. Prescription Card NDC Envoy RxBin or RxPCN CAL or Envoy Acct.# Issuer (80840) «DOI» «subid» «Patientname» «Carrier» Injury Date ID# Name Carrier/TPA

13 Attention Pharmacist: Tmesys is the workers compensation PBM for this patient. For questions regarding transmission, call NDC Envoy RxBin or RxPCN CAL or Envoy Acct.# Issuer (80840) Attention Pharmacist: Tmesys is the workers compensation PBM for this patient. For questions regarding transmission, call NDC Envoy RxBin or 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