Sedgwick Claims Kit Oklahoma

Transcripción

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

2 Dear Insured: We would like to welcome you as a policyholder of Republic Fire & Casualty. 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; AtlasGeneralInsurance@sedgwickcms.com OR: Fax: Where do I send my injured employee for medical treatment? Website: Sedgwick Claim Kit Attachments: Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees (CC-Form-1A) TO BE POSTED IN WORKPLACE Aviso e Instrucción de Compensación de Trabajadores de Oklahoma para Empresarios y Trabajadores (CC-Form-1A Spanish) TO BE POSTED IN WORKPLACE Employer s First Report of Injury Form (CC-Form-2) Flowchart of Workers Compensation Process Understanding the Claims Process Provider Search Tool Job Aid 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. OKLAHOMA Welcome Letter Southern Insurance Co. 4/2014

3 CC-Form-1A Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees All employees of this employer who are entitled to benefits of the Administrative Workers' Compensation Act are hereby notified that this employer has complied with all rules of the Workers' Compensation Commission and that this employer has secured payment of compensation for all employees and their dependents in accordance with the Act. All employees are further notified this employer will furnish first aid, medical, surgical, hospital, optometric, podiatric, and nursing services, medicine, crutches and other apparatus as may be reasonably necessary in connection with the injury received by the employee, as well as payments of compensation to any injured employee or the employee s dependents as provided in the Act. Any employee who has suffered a compensable injury covered by the Administrative Workers' Compensation Act is entitled to vocational rehabilitation services, including retraining and job placement, if, as a result of the injury, the employee is unable to perform work for which the person has previous training or experience. The Oklahoma Workers' Compensation Commission has a Counselor Division to provide information to injured workers, employers, and other interested persons. Mediation is available to help resolve certain workers compensation disputes. For information, call the Counselor Division at or In-State Toll Free Signature of Employer Insurer Name and Address Date of Expiration of Insurance Policy (Not applicable to employers authorized to self-insure.) Employee's Responsibilities In Case of Work Related Injury If accidentally injured or affected by cumulative trauma or an occupational disease arising out of and in the course of employment, however slight, the employee should notify the employer immediately. If this employer is a partnership, notice shall be given to any partner. If this employer is a corporation, notice shall be given to any agent or officer of the corporation upon whom legal process may be served. Notice shall also be given to the person in charge of business at the location of operations where the injury occurred. Unless oral or written notice is given to the employer within thirty (30) days, the claim for compensation may be forever barred. The employee may file a claim for compensation with the WORKERS COMPENSATION COMMISSION for an accidental injury, death, cumulative trauma or occupational disease or illness occurring ON OR AFTER February 1, Forms to file a compensation claim should be furnished by this employer and also are available from the Workers Compensation Commission. The forms are posted on the Commission s website, A claim for compensation must be filed with the Commission within the time specified by law, or be forever barred. Based on law effective February 1, 2014, a claim for compensation for any accidental injury or death must be filed with the Commission within one (1) year of the date of injury or death; a claim for compensation for occupational disease or illness must be filed within two (2) years of the last injurious exposure; and a claim for compensation for cumulative trauma must be filed within one (1) year of the date of injury. A claim for additional compensation is barred unless filed within one (1) year of the last payment of disability compensation or two (2) years from the date of injury, whichever is longer. Claims for compensation for accidental injury, death, cumulative trauma or occupational disease or illness occurring BEFORE February 1, 2014 may be filed with the WORKERS COMPENSATION COURT OF EXISTING CLAIMS and are subject to different notice of injury requirements and claims filing deadlines than those for accidental injury, death, cumulative trauma or occupational disease or illness occurring on or after February 1, Failure to comply with applicable notice requirements and deadlines may operate to forever bar the claim. Contact the Commission s Counselor Division for additional information. Employer's Responsibilities The employer must provide employees with immediate first aid, medical, surgical, hospital, optometric, podiatric, and nursing services, medicine, crutches and other apparatus as may be reasonably necessary in connection with the injury received by the employee. This applies to care for all injuries and illnesses arising out of and in the course of employment, regardless of their character. Within ten (10) days after the date of receipt of notice or knowledge of death or injury that results in more than three days absence from work for the injured employee, the employer MUST send a report thereof to the Workers Compensation Commission on a CC-Form 2, and also send a copy of the CC-Form 2 to the employer s insurance carrier, if any, within the ten-day period. No agreement by any employee to pay any portion of the premium paid by the employer to a carrier or a benefit fund or department maintained by the employer for the purpose of providing compensation or medical services and supplies as required by the workers compensation laws, shall be valid. Any employer who makes a deduction for such purposes from the pay of any employee entitled to benefits under the workers compensation laws shall be guilty of a misdemeanor. No agreement by any employee to waive workers' compensation rights and benefits shall be valid. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both. Workers' Compensation Commission 1915 North Stiles Avenue Oklahoma City, Oklahoma Tele (OKC) (TU) In-State Toll Free Created This notice must be posted and maintained by the employer in one or more conspicuous places on the work premises.

4 CC-Form-1A Aviso e Instrucción de Compensación de Trabajadores de Oklahoma para Empresarios y Trabajadores Se notifica por la presente a todos los empleados de esta empresa que tengan derecho a los beneficios de la Ley de Compensación para Trabajadores Administrativos que este empleador ha cumplido con todas las reglas de la Comisión de Compensación de Trabajadores, y que este empleador ha asegurado el pago de compensación a todos los empleados y sus dependientes en conformidad con la ley. Asimismo, se notifica a todos los empleados que este empleador proporcionará primeros auxilios, servicios médicos, quirúrgicos, hospitalarios, de optometría, podología y enfermería, medicina, muletas y otros aparatos que sean razonablemente necesarios en relación con la lesión sufrida por el trabajador, así como los pagos de compensación a cualquier empleado lesionado o sus dependientes conforme a lo dispuesto por la ley. Cualquier empleado que haya sufrido una lesión indemnizable amparado por la Ley de Compensación para Trabajadores Administrativos tiene derecho a los servicios de rehabilitación vocacional, esto incluye la re-capacitación e inserción laboral si el empleado ya no pudiese realizar el trabajo para el cual tuviese formación o experiencia previa como consecuencia de la lesión. La Comisión de Compensación de Trabajadores de Oklahoma cuenta con una División de Asesoría para proporcionar información a los trabajadores lesionados, empleadores y otras personas interesadas. Existe la posibilidad de mediación para ayudar a resolver disputas de compensación para ciertos trabajadores. Para obtener más información, llame a la División de Consejería al o al número gratuito (dentro del estado) Firma del Empleador Nombre y Dirección del Asegurador Fecha de Vencimiento de la Póliza de Seguro (No aplicable a los empleadores autorizados para auto-asegurarse.) Responsabilidades del empleado en caso de sufrir una lesión relacionada trabajo De resultar dañado o afectado por trauma acumulativo o una enfermedad profesional que surja del empleo y en el transcurso de su desempeño, por leve que sea, el empleado debe notificar al empleador inmediatamente. Si este empleador es una sociedad, se debe notificar a cualquier socio. Si este empleador es una corporación, la notificación se hará a cualquier agente o funcionario de la corporación autorizado a recibir tal notificación. Se notificará también a la persona a cargo de los negocios en el lugar de operaciones donde se haya producido la lesión. De no haber notificado verbalmente o por escrito al empleador dentro de los treinta (30) días, el reclamo de indemnización puede prescribir de forma definitiva. El empleado puede presentar un reclamo de indemnización ante la COMISION DE INDEMNIZACION de TRABAJADORES por una lesión accidental, muerte, trauma acumulativo o enfermedad profesional o enfermedad accidental que ocurra EL 1 de febrero de 2014, O DESPUÉS de esa fecha. Este empleador debe suministrar los formularios para presentar un reclamo de compensación, y también se encuentran disponibles en la Comisión de Compensación de los Trabajadores. Los formularios se encuentran publicados en el sitio web de la Comisión, El reclamo de compensación debe ser presentado ante la Comisión en el plazo fijado por la ley, o prescribirá para siempre. En virtud de la ley vigente a partir del 1 de febrero de 2014, los reclamos de indemnización por cualquier lesión o muerte accidental se deben presentar ante la Comisión dentro de un (1) año transcurrido a partir de la fecha de la lesión o muerte; los reclamos de indemnización por males o enfermedades profesionales se deben presentar dentro de los dos (2) años transcurridos a partir de la última exposición perjudicial; y los reclamos de indemnización por trauma acumulativo se deben presentar dentro de un (1) año transcurrido a partir de la fecha de la lesión. Se prohíben los reclamos de indemnización adicional a menos que sean presentados dentro de un (1) año transcurrido a partir del último pago de compensación por discapacidad o dos (2) años desde la fecha de la lesión, el período que sea mayor. Los reclamos de indemnización por lesiones, muerte, trauma acumulativo o males o enfermedades profesional accidentales que ocurrieran ANTES del 1 de febrero de 2014 se pueden presentar ante el TRIBUNAL DE RECLAMOS EXISTENTES DE COMPENSACIÓN AL TRABAJADOR y estarán sujetos a diferentes requisitos de notificación de la lesión y distintos plazos para presentar reclamos a los requeridos para los correspondientes a lesiones accidentales, muerte, trauma acumulativo o males o enfermedades profesionales que ocurrieran a partir del 1 de febrero de El incumplimiento de los requisitos y los plazos de notificación aplicables puede resultar en la prescripción definitiva del reclamo. Póngase en contacto con la División de Asesoría de la Comisión para obtener información adicional. Responsabilidades del Empleador El empleador debe proporcionar a los empleados primeros auxilios, servicios médicos, quirúrgicos, hospitalarios, de optometría, podología, así como servicios de enfermería, medicina, muletas y otros aparatos que sean razonablemente necesarios en relación con la lesión sufrida por el empleado. Esto es aplicable al cuidado de todas las lesiones y enfermedades que surjan del empleo y el transcurso de su desempeño, independientemente de su carácter. El empleador DEBERÁ enviar, dentro de los diez (10) días a partir de la fecha de recepción de la notificación o el conocimiento de la muerte o lesión que resulte en más de tres días de ausencia del trabajo del empleado lesionado, un informe sobre esto a la Comisión de Compensación del Trabajador en un formulario CC-Form 2, y también deberá enviar una copia de ese formulario a la compañía aseguradora del empleador, si la hubiere, en el plazo de diez días. Se invalidará cualquier acuerdo hecho por un empleado para pagar cualquier porción de la prima pagada por el empleador a un operador, fondo de prestaciones o departamento mantenido por el empleador con el fin de indemnizar o proveer servicios y suministros médicos, tal como lo requieren las leyes de compensación de los trabajadores. Cualquier empleador que realice una deducción del pago de cualquier empleado con derecho a prestaciones en virtud de las leyes de compensación de los trabajadores para tales propósitos será culpable de un delito menor. Se invalidará cualquier acuerdo hecho por un empleado para renunciar a los derechos y beneficios de compensación del trabajador. Toda persona que cometa fraude de compensación del trabajador, será culpable, de ser condenada, de un delito grave punible con pena de prisión, una multa o ambas. Comisión de Compensación del Trabajador 1915 North Stiles Avenue Oklahoma City, Oklahoma Tel (OKC) (TU) Línea gratuita (dentro del estado) Sitio Web Creado Este aviso debe ser publicado y mantenido por el empleador en uno o más lugares visibles en el lugar de trabajo

5 CC-FORM-2 Applicable to Injuries /Deaths Occurring On or A er 2/1/14 Send original to Workers Compensa on Commission and 1 copy to Insurance Carrier Please type or print. Enter all dates in MM/DD/YY format. Full Name of Employee - LAST, FIRST, MIDDLE WORKERS COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK EMPLOYER S FIRST NOTICE OF INJURY Employee Address THIS SPACE FOR COMMISSION USE ONLY Complete Address City State Zip Telephone Number Date of Birth Average Weekly Wage Sex Occupa on (job descrip on) Employee s Social Security Number (LAST 4 DIGITS ONLY) XXX-XX- Length of Employment: Years Months Date of Hire: Was employment agreement made in Oklahoma? YES NO NOTE: Mediation is available to help resolve certain workers compensation disputes. For information, call (405) or In-State Toll Free (800) Date of accident or last exposure Time of accident or exposure o clock AM PM Date Employer No fied Time workday began o clock AM PM Last date employee worked OSHA Log Case # Has employee returned to work? YES NO If yes, on what date? Did the employee die? YES NO If yes, on what date? Place of Accident or Occurrence City: County: State: Injury Resulted from: Single Incident Cumula ve Trauma Occupa onal Disease Nature of Injury or Illness Does employee par cipate in a cer fied workplace medical plan: YES NO If yes, name of CWMP: Describe ac vi es when injury occurred with details of how event occurred. Include object or substance which directly injured the employee. Iden fy part(s) of body involved in injury or illness Full Name and address of Trea ng Physician (please be complete) Employer s Insurance Carrier or Own Risk Group Policy/Self-Insured Number Name Phone Policy Period: From To Address City State Zip Employer s Name and Complete Address Name Federal ID# Phone # Address City State Zip Type of business (Example: manufacturing, food service, construc on) NAICS Number Type of Ownership: Private State Government County Government Local Government Administra ve Workers Compensa on Act, 85A O.S., 6(A)(1)(a): Any person or en ty who makes any material false statement or representa on, who willfully and knowingly omits or conceals any material informa on, or who employs any device, scheme, or ar fice, or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment shall be guilty of a felony. Any person who commits workers compensa on fraud, upon convic on, shall be guilty of a felony punishable by imprisonment, a fine or both. The undersigned hereby declares under PENALTY OF PERJURY that they have examined this no ce and all statements contained herein are true, correct and complete, to the best of their knowledge. The undersigned cer fies this CC-Form 2 was sent to the Workers Compensa on Commission and a copy thereof to the employer s insurer on the date noted below: Signed By Telephone Number Date Signature of Preparer Name and Title of Preparer (Please Print) Area Code and Number A CC-Form 2 must be sent to the Workers Compensa on Commission and to the employer s workers compensa on insurance carrier within 10 days a er the date of receipt of no ce or knowledge of death or injury that results in more than three days absence from work for the injured employee. PROVIDING THIS FORM TO THE COMMISSION IS NOT EVIDENCE OF ANY FACT STATED IN THE REPORT IN ANY PROCEEDING WITH RESPECT TO THE INJURY OR DEATH ON ACCOUNT OF WHICH THE REPORT IS MADE. Revised

6 BG Monday, June 02, 2014 FOR ILLUSTRATIVE PURPOSES ONLY! Not intended to provide legal advice or replace your own legal counsel TIMELINE OF ALJ/COMMISSION CASES BEGINNING FEBRUARY 1, 2014

7 BG Monday, June 02, 2014 Case assigned to Administrative Law Judge for hearing 85A O.S. 71(B); 810: (a)

8 BG Monday, June 02, 2014

9 BG Monday, June 02, 2014

10 Understanding the Claims Process - A Guide for Injured Workers (On-the-Job Injury, Illness or Death Occurring on or after February 1, 2014) Notice of Injury to Employer: It is important to give immediate notice to your employer about your injury. Generally, if not done within 30 days, you may lose your rights to any workers compensation benefits. Employer Report of Injury: Employers are required to file a report with the Commission within 10 days of having knowledge of any work death or injury that results in more than 3 days away from work. This is not a claim and does not protect your rights. Injured Worker Notice: Once the Commission receives the employer s report of injury, the Commission will send you a notice about the Commission s Counselor Division and its mediation services. The notice explains how the Counselor Division may help you throughout the claims process and includes contact information. You are not required to have a lawyer to process your claim. Employer Statement of Intent: You are entitled to a statement from the employer or its insurance carrier of its intent to accept or deny any right to compensation. The statement (CC- Form-2A) is to be sent to you within 15 days of the employer s receipt of notice of the injury, unless the time is extended by the Commission. If the time is extended, you will receive a copy of a document called the CC-Form-2A Extension. The extension allows the employer more time to gather information about the injury and file the CC-Form-2A. Mediation: If the employer/carrier statement of intent denies the right to compensation, you may contact the Counselor Division for information about mediation. Mediation is voluntary and informal. It is a process in which a neutral person helps the parties understand, and work toward an agreed upon resolution of, their dispute. Mediation may be used at any time during the claims process. Claim for Compensation: You may file a claim for compensation with the Commission to protect your rights. The claim must be filed within the time fixed by law. A claim for compensation for injury (CC-Form-3) must be filed within one (1) year of the date of injury. Other types of claims for compensation have different filing deadlines. Failure to comply with the deadlines may cause the claim to be forever barred. Claims forms are on the Commission s website, They also are available at both Commission locations, 1915 N. Stiles Avenue, Oklahoma City, OK and 210 Kerr State Office Building, 440 S. Houston, Tulsa, OK To file, mail or hand deliver the completed claim form to either location. Prehearing Conference and Hearing: After a claim for compensation is filed, you may request a prehearing conference or hearing before a Commission Administrative Law Judge (ALJ) to address any disputed issues. The Counselor Division may help you with the request. A prehearing conference is an informal meeting between the parties and the ALJ. It is held before a hearing is scheduled. The prehearing conference gives the parties a chance to resolve disputes by agreement or with the help of the ALJ, and to discuss settlement.

11 Hearings are only necessary if you and the employer/carrier cannot resolve the dispute. A hearing is a formal proceeding before an ALJ. The ALJ will hear evidence presented by you and the employer/carrier at the hearing. Your evidence may include medical records and other documents, your testimony and testimony from any witnesses. The ALJ will decide the dispute based upon the law and the evidence admitted at the hearing. The ALJ s written decision will be sent to you and the employer/carrier within 30 days after the record closes. Appeal: Any party has 10 days from the date of the ALJ s decision to file an appeal to the full Commission. Any party has 20 days from the date of the full Commission s decision to file an appeal to the Oklahoma Supreme Court. Settlement: You may settle all or part of your claim for compensation for an injury by coming to an agreement with the employer/carrier at any time during the claims process. Settlement avoids the need for a formal hearing. The terms of the settlement will need to be put in writing on a document called a Joint Petition Settlement. The settlement must be approved by an Administrative Law Judge of the Commission. Questions or need additional information? Contact the Commission s Counselor Division. Our staff is available to help you.

12 VIAONE PROVIDER SEARCH TOOL ACCESS INFORMATION AND INSTRUCTIONS Provider Search Tool Access: Access Link Login Password Client SedgwickCMS_123 Provider Search: Search for Providers several ways: 1. Enter Zip Code, City, State or Distance 2. Enter a specific Address to narrow search results 3. Enter a Phone Number to search for a specific provider s phone number 4. Enter a License number or Tax Identification Number (TIN) 5. Enter partial or full spelling of Group or Provider Name 6. Check the First Treaters box only to receive first treating providers in the search results 7. Check the Hospitals / Facilities box only to receive hospitals / facilities in the search results 8. Check the First Treaters box and Hospitals / Facilities box to receive both types of providers in the search results 9. Check all three boxes to search all provider types and specialties Page 1 of 3

13 VIAONE PROVIDER SEARCH TOOL ACCESS INFORMATION AND INSTRUCTIONS 10. Check the Other box and narrow the search results to specific specialties Network Dropdown Box: When searching in CA, TX or NY, the system will ask you to choose a network; then search. CA Network Options: Sedgwick National No MPN Sedgwick Standard MPN Sedgwick Extended MPN **Note provider directories for the MPN s listed below should be printed from: Sedgwick Standard MPN: Sedgwick Extended MPN: TX Network Options: Sedgwick National No HCN Coventry TX HCN SWMPN Southwest HCN NY Network Options: Sedgwick National Sedgwick DOC Sedgwick ROC The networks listed above differ depending on individual participation. The user must select the correct network before searching. Page 2 of 3

14 VIAONE PROVIDER SEARCH TOOL ACCESS INFORMATION AND INSTRUCTIONS Search Results: When the search results populate, you can view them by Specialty, Group or Provider. The number to the right of the specialty is a count of the number of providers / groups. To expand the specialties, click on the + symbol to the left of the specialty name To collapse the listing, click on the - symbol To filter the search results, use the filter button on the far right hand side of the screen. Click on the drop-down box next to the appropriate title Status: P = Provider is on a provider listing panel V= Provider has been validated within 6 months VP= Valid provider on a provider listing panel Page 3 of 3

15 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.

16 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

17 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

18 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

19 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

20 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