The following state forms have been included in your claims kit packet:

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RE: Workers Compensation Claims Kit Dear Policyholder:

Welcome to Tower Group Companies’ Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee, we want you to have all the information you might need in the event one occurs.

Enclosed is our Workers Compensation Injury Reporting Kit that contains the Virginia state-mandated forms and a step-by-step process to follow in case of an employee sustains an injury. When a claim occurs, see the attached instructions for reporting a claim to our Claims Intake Unit. The contact information for the Claims Intake Unit is listed on the “How to File an Injury” form included in this packet. The Tower Group claim office which will be handling your claim is located in Irving, Texas. Once reported, a claims representative will contact you to obtain additional information about the injured employee and to answer any questions that you might have regarding the Virginia workers compensation process.

The following state forms have been included in your claims kit packet:

1. Virginia Employer’s Accident Report- VWC- Form#3 – Employers Accident Report-

Pursuant to Section 65-2-900 of the Virginia Code and Section 65-2-902 of the Virginia Code, every employer has the duty to report an accident within ten (10) days of the occurrence and knowledge of occurrence. The failure to do so may result in a $500 fine, and if the Virginia Compensation Commission deems this failure to be willful, the fine can be up to $5,000.

2. Virginia Claim Form and Request for Hearing- VMC form#5- Even if the injured employee has been paid by his/her employer or claim administration for time missed from work because of an injury or for medical treatment for the injury, the employee must file a claim with the Virginia Workers Compensation Commission to protect his/her rights to benefits under Virginia Law. File this form with Part A completed, with the Virginia Workers Compensation Commission as soon as possible. If the employee is requesting a hearing, the employee must file medical reports supporting his/her request with the Virginia Workers Compensation Commission and complete Part B of this form and submit the medical reports either attached to the form, or as soon as possible.

3. Virginia Form No. 7A- Wage Chart- If the average weekly wage is contested, the employer shall timely file a wage chart showing all wages earned by an employee in its employment for the term of the employment, not to exceed one year prior to the date of injury.

4. Medical Authorization- Please have the injured employee fill out and sign this form and send to Tower Group Companies at the time of an injury.

We thank you for your business and look forward to being of service to you. Very truly yours,

Tower Group Companies

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H

OW TO FILE A WORK INJURY OR

I

LLNESS

C

LAIM

Workers compensation claims can be reported in several different ways, you can:

Complete and submit the

Virginia Employer’s Accident Report- VWC- Form#3 –

Employers Accident Report-

and submit the form via one of the following:

E-mail the completed form to

wcreportaloss@twrgrp.com

.

This is the

preferred method of reporting an injury

.

Fax to Tower Group Companies at 888-535-3407.

Call the Tower Group Companies Claims office at 888-856-5522.

By contacting your broker directly and providing the appropriate first report

information.

For injuries occurring after normal business hours, please call 888-856-5522.

The

after hours telephone number for reporting claims provides the opportunity to

report a claim 24 hours a day 7 days a week. Loss details will be gathered to

determine if an emergency exists and if an immediate field contact is indicated.

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Employer’s Accident Report

Reason for filing VWC file number (formerly: Employer’s First Report of Accident) The boxes

Virginia Workers’ Compensation Commission to the right Insurer code or PEO Ref. No. Insurer location 1000 DMV Drive Richmond VA 23220 are for the

See instructions on the reverse of this form

use of the Insurer claim number insurer

Employer

1. Name of employer (trading as or doing business as, if applicable) 2. Federal Tax Identification Number 3. Employer’s Case No. (if applicable) 4. Mailing address 5. Location (if different from mailing address)

6. Parent corporation /Policy Named Insured (if applicable) or PEO name 7. Nature of business (NAICS code, if applicable)

8. Name and Address of Insurer or self-insurer for this claim 9. Policy number 10. Effective date

Time and Place of Accident

13. Hour of injury a.m. p.m. 11. City or county where accident occurred 12. Date of injury

13a. Time began work a.m. p.m.

14. Date of incapacity 15. Hour of incapacity

16. Was employee paid in full for day of injury? 17. Was employee paid in full for day incapacity began? Yes No Yes No

18. Date injury or illness reported 19. Person to whom reported 20. Name of other witness 21. If fatal, give date of death Employee

22. Name of employee (Last, First, Middle) 23. Phone number 24. Sex

Male Female

25. Address 26. Date of birth 27. Marital status

Single Divorced

28. Social security number

Married Widowed

29. Occupation at time of injury or illness (SOC code, if applicable) 30. Is worker covered by PEO policy? 31. Number of dependent

Yes No children

32. How long in current job? 33.Date of Hire 34. Was employee paid on a piece work

or hourly basis? Piece work Hourly 35. Hours worked 36. Days worked 37. Value of perquisites per week

per day per week Food/meals Lodging Tips Other 38. Wages per hour 39. Earnings per week (inc. overtime)

$ $ $ $ $ $ Nature and Cause of Accident

40. Machine, tool, or object causing injury or illness 41. Specify part of machine, etc. 42. Describe fully how injury or illness occurred

43. Describe nature of injury or illness, including parts of body affected 43a. Overnight inpatient hospitalization? Yes No

43b. Treated in Emergency Room? Yes No 44. Physician (name and address) 45. Hospital or Clinic (name and address)

46. Probable length of disability 47. Has employee returned If 48. At what wage? 49. On what date? to work? Yes No yes

50. EMPLOYER: prepared by (name, signature, title) 51. Date 52. Phone number

53. INSURER: (name of processor) 54. Date 55. Phone number

56. THIRD PARTY ADMINISTRATOR (if applicable) 57. Address 58. Phone number

This report is required by the Virginia Workers’ Compensation Act Employer’s Accident Report

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FILING INSTRUCTIONS

(Instructions Updated 09/01/07)

Employer’s Accident Report

VWC Form No. 3

This form must be completed by the employer, the employer’s representative or the insurer and filed within 10 days after the notice of a work-related injury, occupational illness/disease or if the occurrence resulted in death to the worker. If the employer or its representative completed the form, the form should be submitted to the insurer who provided insurance coverage on the date of the occurrence, and the insurer will immediately file the original and one copy of the completed form with the Virginia Workers’ Compensation Commission, 1000 DMV Drive, Richmond, VA 23220. The additional copy of the Employer’s Accident Report (VWC Form No.3) will be furnished to the Virginia Department of Labor and Industry. The filing of this form with the Commission is a requirement under §65.2-900 of the Act.

Employer

1. As the employer, you are responsible for accurately completing all sections of this form when one of your employees is injured. It should be typed or legibly printed, signed, and dated by the preparer. Your insurance carrier, claims servicing agency, self-insured employer’s representative or third-party administrator should complete the information in the top right corner.

2. The “trading as” or “doing business” as name should appear in Block l and the Parent Corporation (policy named insured) should be reflected in Block 6.

3. Provide the insurance information (name, address, policy number, and effective date of the policy), that covers the date that the work-related accident or occupational illness or disease occurred, in Blocks 8, 9 and 10.

4. As the employer, if you are subject to OSHA record-keeping requirements, a copy of this completed form may be retained as a supplementary record of an occupational illness or disease. Use Block 3 (Employer’s Case No.) to cross-reference any master-log of work-related accidents, illnesses, diseases and death claims.

5. Send the original beige form to your insurance carrier, claims servicing agency, or third-party administrator for processing.

Insurance Companies, Self-Insurers, Servicing Companies, Authorized Representatives, Third-Party Administrators (TPA’s), Group Self-Insurance Associations, and Professional Employer Organizations (PEO’s):

1. The insurer should provide the information at the top right of the form. Use a numerical code (1-7) to indicate the

reason for filing the form for accidents meeting one of the filing criteria’s*. When using a code reason (7) provide the VWC file number. Note that the insurer code refers to the five-digit numeric code assigned by the National Counsel on Compensation Insurance (NCCI). The Virginia Workers’ Compensation Commission assigns self-insured employers a similar five-digit code number. Professional Employer Organizations (PEO’s) must use the VWC reference number.

2. If the work-related accident or occupational illness or disease does not meet one of the filing criteria*, a Report of Minor Injuries (VWC Form 45-A) should be completed for the occurrence and timely filed with the Virginia Workers’ Compensation Commission.

3. Verify the insurance information that was provided by the employer (name, address, policy number, and effective date of the policy) as it appears on this form and ensure that it covers the date that the accident or occupational illness or disease occurred (Blocks 8, 9 and 10).

4. Provide the applicable information requested in Blocks 50 through 58 as it applies.

Forms: Additional copies of this form are available without cost by writing to the Commission. Address your inquiries to “Forms” at the listed Virginia Workers’ Compensation Commission address. This form is also available on the

Commission’s website, at www.vwc.state.va.us. Note: color-coding of the forms greatly increases the Commission’s efficiency in processing claims, and that any alternative versions of the form you develop yourself require prior approval by the Commission. The original copy of theEmployer’s Accident Report (VWC Form No.3) should be on beige paper.

Electronic Filing: The Employer’s Accident Report (VWC Form No. 3) can be filed electronically through the

Commission’s Website, at www.vwc.state.va.us. For questions or assistance regarding the electronic filing process, please contact our “Information Systems Department” at (804) 367-2254 or in writing. Also, provide a brief description of your current data processing and communication capabilities.

For questions or assistance with completing the form, please contact the First Report’s Unit at (804) 367-0072 or the Commission’s Toll-free number at (1-877) 664-2566.

*The criteria’s for filing are (1) lost time exceeds seven days, (2) medical expenses exceed $1,000, (3) compensability is denied, (4) issues are disputed, (5) accident resulted in death, (6) permanent disability or disfigurement may be involved, and (7) a specific request is made by the Virginia Workers’ Compensation Commission.

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(6)

VWC Form #5

Rev.10/08

Claim Form &

Request for Hearing

Virginia Workers’ Compensation Commission

1000 DMV Drive Richmond Virginia 23220 1-877-664-2566

SEE INSTRUCTIONS ON REVERSE SIDE www.vwc.state.va.us

Jurisdiction Claim #:

Claim Administrator #:

Injured Worker’s Name: Address:

City: State: Zip:

Home Phone: Work Phone:

Employer's Name: Address:

City: State: Zip:

Employer’s Phone:

Parts of Your Body Injured: __________________________________________________________________________________________________ __________________________________________________________________________________________________

Date of Injury*: Average Earnings per week: $

*in case of disease, give date doctor told you that disease was caused by work

PART A (Claim Form) (All injured workers should complete this section for workers’ compensation injuries)

I hereby file this claim to protect my rights under the Virginia Workers’ Compensation Act for the injury or disease described above. I am not requesting the Commission take any specific action at this time.

________________________________ ______________________________ ______________ Injured Worker’s signature Print Name Date

Please sign and return to the Commission. Complete Part B below only if you are requesting a hearing.

Part B (Request for Hearing) (You are not required to complete this section—do so only if you are requesting a hearing) I hereby request a hearing from the Commission. I am seeking the following:

An Award for medical benefits for my injury (including any treatment already received & paid for) **

I missed work because of my injury on (dates) ____________________________________________________ ** I earned less pay because of my injury on (dates) __________________________________________________** I have a loss of or loss of use of a body part or have disfigurement. **

I have unpaid medical bills relating to my injury. **

Other _______________________________________________________________________________

________________________________ ______________________________ ______________ Injured Worker’s signature Print Name Date

** Attach medical records or bills.

If there are any questions regarding this form, please contact the Commission toll-free at 1-877-664-2566.

BARCODE

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Claim Form &

Request for Hearing

VWC Form #5

Filing Instructions

1. Even if you have been paid by your employer or claim administrator for time missed from

work because of your injury or for medical treatment for your injury, you must file a claim

with the Virginia Workers’ Compensation Commission to protect your right to benefits under

Virginia law. File this Claim Form, with Part A completed, with the Commission as soon as

possible.

2. For questions or assistance with completing this form, please contact Customer Assistance

using the Commission’s toll-free number 877-664-2566.

3. If you are requesting a hearing, you must file medical reports supporting your request with

the Commission. If you are requesting a hearing, complete Part B of this form and submit

the medical reports either attached to the form, or as soon as possible.

4. If you are not requesting a hearing at this time, you may do so at a later date, but you should

still submit this form with Part A completed. To request a hearing at a later date, please

contact the Commission at 877-644-2566 or the Commission’s website at

www.vwc.state.va.us

to obtain another copy of this form.

5. You may obtain copies of your medical records directly from your physician. Please contact

the Commission at 877-644-2566 for assistance.

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Wage Chart

Employer’s Statement of Wage Earnings

Virginia Workers’ Compensation Commission

1000 DMV Drive Richmond VA 23220

PLEASE REFER TO THE FILING INSTRUCTIONS PRINTED ON THE BACK OF THIS FORM

Week No. Week Ending Date Days Worked Gross amount paid, including overtime Week No. Week Ending Date Days Worked Gross amount paid, including overtime Week No. Week Ending Date Days Worked Gross amount paid, including overtime 1 19 37 2 20 38 3 21 39 4 22 40 5 23 41 6 24 42 7 25 43 8 26 44 9 27 45 10 28 46 11 29 47 12 30 48 13 31 49 14 32 50 15 33 51 16 34 52 17 35 18 36 Totals

Value of perquisites for entire year: Total gross earning $ ____________ Total weeks worked _______

Bonuses $ Electricity $ _______

Meals/Lodging $ Water $ Total value of perquisites $_____________

Meals Only $ Telephone $ _______ Temporary Lodging $ Uniforms $ _______

House Rent $ Laundry $ Total earnings & perquisites $ _____________

Tip Income $ ________

Wage Chart

VWC Form No. 7A (rev. 07-01-06)

VWC use only:

AWW: ________

CR: ________

INSURER OR EMPLOYER (include name & signature) Date Telephone number

Employee Address

Name of Employee Date of Accident Date of Hire

Employer Address

Name of Employer Employee’s Social Security Number

The boxes Reserved VWC File Number to the right

are for the

use of the Insurer Code Insurer Location insurer.

Insurer Claim Number

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FILING INSTRUCTIONS

(Instructions Updated 09/01/07)

Wage Chart

VWC Form No. 7A

The information at the top right of the form should be provided by the insurer. Please note that the insurer code refers to the five-digit numeric code assigned by The National Counsel on Compensation Insurance (NCCI). Self-insured employers are assigned a similar five-digit code number by the Virginia Workers’ Compensation Commission.

Illegible forms will be returned to the insurer.

How to complete the Wage Chart:

x Indicate gross weekly earnings for the 52 weekly periods immediately preceding the date of accident. x Note that these earnings are GROSS earnings and include overtime and tips, before any deductions are

made for taxes or Social Security. If there were any perquisites, please list the TOTAL value separately at the bottom of the chart.

x If an injured employee lost more than seven consecutive calendar days, although not in the same week, these periods should be noted on the Wage Chart (VWC Form No. 7-A) using an asterisk in the Week No. column and are not to be counted in the calculations. Va. Code § 65.2-101.

x If injured employee has worked less than 12 months, the earnings for the time worked should be used. The earnings for a similar employee may be used if the employee has worked less than 60 days.

How to calculate the Wage Chart

:

x If a full year’s wage information has been provided covering the 52 week period prior to the date of accident:

- determine the total wages earned, including yearly perquisites; - divide the total wages earned for this period by 52;

- the sum will be the average weekly wage.

x If a full year’s wage information has not been provided covering the 52 week period prior to the date of accident:

- determine the total wages earned, including yearly perquisites;

- divide the total wages earned by the number of weeks wages were earned (Note: if warranted, the weeks can be converted into days and calculated on that basis);

- the sum will be the average weekly wage. x If the form is completed on a bi-weekly basis:

- determine the total wages earned, including yearly perquisites;

- divide the total wages earned by the number of weeks worked (employee paid 26 times a year represents 52 weeks of wages);

- the sum will be the average weekly wage.

x Samples of properly completed wage chart(s) are available through the Commission’s Website at www.vwc.state.va.us under the forms menu.

x

For questions or assistance with completing this form, please contact the Awards Unit using the Commission’s Toll-Free number at (1-877) 664-2566.

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W

ORKERS

C

OMPENSATION

I

NJURY

M

EDICAL

A

UTHORIZATION

Authorization for Medical Records

And Communication Release

By this form or copy thereof, I

, hereby authorize any licensed physician, chiropractor, medical practitioner, hospital, clinic or other related medical or medically related facility, insurance company or other organization, institution, or person, that has any records or knowledge of my mental, physical health, history, condition or well being, to supply such information to my employer, it’s insurer, claims administrator, rehabilitation or medical management consultant or attorneys.

I specifically authorize any treating physician or medical care provider to communicate orally or in writing with my employer, it’s insurer, claims administrator, rehabilitation or medical

management consultant or attorneys as to my care and treatment and as to any other issues including but not limited to diagnosis, prognosis, causal connection of care and treatment to my work injury or duties and ability to work. In conjunction with this, I authorize any treating physician or medical provider to review any additional medical records provided to them. I understand that by signing this authorization for medical records and communication release that my applicable medical provider will be releasing information subject to the HIPPA

restrictions. I specifically waive any rights or protections that I may have under the HIPPA regulation and request that the medical providers release the requested information.

A photo copy of this authorization shall be valid as the original. This release shall remain valid for the length of my claim.

Name (Please Print)

Address (Street, City/Town, Zip Code)

Signature

Date Signed

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W

ORKERS

C

OMPENSATION

M

ANAGED

C

ARE

P

ROGRAMS

Tower Group Companies strives to deliver the highest quality and value of workers compensation products and services to our customers. We are committed to providing excellent customer service and products which will meet our customers’ needs in managing their workers compensation claims.

Tower Group Companies participates in several Managed Care Initiatives through a Partnership with Coventry Workers Comp Services. These initiatives help to reduce workers compensation medical related expenses with a focus of timely return to work for your injured worker.

A summary of each program is outlined below.

Medical Bill Review Services

The Medical Bill Review Services Program provides an opportunity to reduce your medical costs. The program helps to obtain the maximum savings available on every bill by processing each bill through an extensive database of state fee schedules, usual and customary charge reviews, diagnostic related group reviews, and national Preferred Provider Organizations (PPO) Network discounts. Additional savings are obtained by hospital bill auditing and out of network negotiation programs.

Network Providers - Coventry Workers Comp Services provides one of the largest national workers compensation discount networks in the industry. It is comprised of the First Health, FOCUS, MetraComp, and

Aetna networks; as well as other top regional PPO’s. The combination of these network providers offers

coverage in every jurisdiction in the country resulting in superior network savings and increased medical provider availability. These networks are comprised of medical providers specializing in occupational medicine and services focusing on quality of care and expedited return to work for the injured employee. Coventry credentials each provider within the network to provide quality medical service and who is dedicated to returning the injured employee to work.

In some states, such as California and Texas state regulations allow ‘specialty networks’ which provide you as an employer more control over your workers compensation medical and disability costs. The physicians within these networks are educated in evidence based treatment protocols assisting the injured employee in reaching early Maximum Medical Improvement (MMI) in accordance with medical industry guidelines. Other benefits include reduction in over utilization of medical services and excessive treatment costs with the focus in early return to work, thereby reducing your workers compensation indemnity payments.

One of the first steps in providing quality medical care to your injured employee is to understand how to

access network providers, and generate workplace provider panel cards or provider listings.

There are two convenient ways to locate a network provider or develop provider network listings:

1. Telephonically: Simply call Coventry at 1-800-243-2336 x 4680. Provide the Coventry representative your employer information, the specific provider specialty you need and your geographic area (city, state and zip code). The Coventry representative will provide verbally provide you with a list of providers meeting your requirements or an electronic provider directory can be forward to you via e-mail.

2. Internet Access:

 For the standard national workers compensation network go to

www.talispoint.com/cvty/twrgrp

and select the Coventry Integrated Network to search for providers in your geographic network. You will be able to generate provider directories as well as determine whether a specialty physician is a member of the Network.

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• If you participate in a Specialty Network, such as a MPN or HCN, select the applicable

network from the drop-down box. For California, chose the First Health Select CA MPN; Texas participants in the Coventry HCN.

For large panel card production or if you require additional information regarding web access

please contact Tower Group Medical Management division at 312-277-1600

.

Medical Case Management - Coventry Workers Comp Services provides you with a variety of programs to help manage the care of your injured employees, including medical case management, catastrophic case management, vocational case management, utilization reviews (URAC certified), return-to-work programs, and independent medical examinations. All of these programs are dedicated to advocating appropriate, high-quality medical treatment, facilitating prompt return to work and effectively managing your claim costs. Experienced medical professionals work with treating physicians and your claims adjuster as advocate for the injured employee’s medical care. These professionals ensure that your employee receives the most appropriate and timely care. Facilitating effective communication between medical providers and claims adjusters also provides a quicker resolution of your claims.

Tower’s dedicated team of adjusters will facilitate the integration of these products and services to assist in reducing injured employee’s lost time and medical costs. Your Tower Group designated adjuster will be responsible for managing all aspects of the injured employee’s claim and facilitating open lines of communication between all parties to resolve any outstanding issues or concerns. Please feel free to contact your claims adjuster, or Tower Group Managed Care Services, if you have any questions regarding these programs.

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Re: Important Information about your Workers’ Compensation Prescriptions

This letter is provided to inform you that your employer’s workers’ compensation, Tower Group

Companies, has selected PMSI as its workers’ compensation pharmacy partner.With PMSI, you can

choose to pick-up your medications for your work-related injury at a nearby pharmacy through a

program known as Tmesys

®

,

or have them delivered to your home through the mail.

Within the next few weeks, you will receive a new workers’ compensation pharmacy card in the mail.

You should give the Tmesys card to the pharmacist at a participating pharmacy of your choice with your

next refill or new prescription for your work-related injury.

If you do not receive your new pharmacy card within two weeks, please call Tmesys at 1.866.599.5426

and we will be happy to assist you or send another card. If you are interested in finding out about how

to receive your prescriptions through the mail, please call 1.800.304.1764.

To help you transition to the new pharmacy program, we have

provided answers to some frequently asked questions:

Q: How do I know if my pharmacy participates with the new program?

A: You can find out if your normal preferred pharmacy is part of the Tmesys network by referring to the

Pharmacy Center on our website, www.pmsionline.com/pharmacy-center. Click on “Pharmacy

Locator” and select how you would like to search for a nearby pharmacy. You may also call the

helpdesk at 1.866.599.5426 to find a network pharmacy near you.

Q:

How does this affect my workers’ compensation claim?

A:

Using PMSI’s program for your workers’ compensation medications will enable you to continue to

receive your prescriptions for your work-related injury. You may choose to visit your local pharmacy,

as long as the pharmacy is one of the more than 60,000 pharmacies in the Tmesys network, or you

can have your prescriptions delivered to your home through our convenient mail order program.

Q: Who do I call with questions about the program?

A: PMSI has representatives available to help you with any questions that you may have about the

pharmacy program. Please call our help desk at 1.866.599.5426 to speak to a representative. If you

have any questions about your workers’ compensation claim, we will help you reach your claims

adjuster for assistance.

We look forward to serving you and meeting your workers’ compensation medication needs.

Sincerely,

PMSI

¿Necesitas ayuda en

español? Llame al

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(To create a card for your wallet, cut along outer line and fold in half.)

Employer:

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.

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 866.599.5426.

CARRIER / TPA EMPLOYER

SOCIAL SECURITY NUMBER DATE OF INJURY

INJURED WORKER NAME Prescription Card

NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct. #

Tmesys Pharmacy Help Desk 800.964.2531

First Fill

Temporary Pharmacy Card

Making it easy to get your workers’ compensation prescriptions filled.

Pharmacist:

1. Call the Tmesys Pharmacy Help Desk at

800.964.2531.

2. Provide the information from the card.

3. The Help Desk will provide an ID number for adjudication.

Finding a Network Pharmacy

Use one of these easy methods to find a network pharmacy:

Visit your local

Walgreens

or

Rite Aid

Pharmacy

Call us:

866.599.5426

Use our pharmacy locator online:

www.tmesys.com

.

© 2011 PMSI, Inc. All rights reserved. C1257-1011-02 . .

Attention Pharmacists: Call 800.964.2531 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.

Questions?

Call 1.866.599.5426

¿Necesitas ayuda en

español? Llame al

1.866.599.5426

(15)

(Para crear una tarjeta para su billetera, corte a lo largo de la linea exterior y doblar por la mitad.)

Employer:

Immediately upon receiving notice of injury, fill in the

information below and give it to your employee.

Empleado Lesionado:

1. Si usted necesita una receta para un accidente de

trabajo o enfermedad ocupacional, ir a una farmacia

de la red Tmesys.

2. Dar esta página al farmacéutico.

3. El farmacéutico surtir su receta sin costo alguno.

Aviso a los titular de la tarjeta: Esta tarjeta debe ser presentada a su farmacia para recibir medicamento para tratar su lesión relacionada con el trabajo.Sólo es válido dentro de los 30 días de su fecha de la lesión. Para obtener información acerca del programa o para encontrar farmacias cercanas llame 866.599.5426.

PORTADORA EMPLEADOR

NUMERO DE SEGURO SOCIAL FECHA DE LA LESIÓN

NOMBRE DEL TRABAJADOR LESIONADO Prescription Card

NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct. #

Tmesys Pharmacy Help Desk 800.964.2531

First Fill Temporary Pharmacy Card

En Primer Relleno Tarjeta Temporal de Farmacia

Hacerlo fácil de llenar sus recetas de la compensación del trabajador.

Pharmacist:

1. Call the Tmesys Pharmacy Help Desk at

800.964.2531.

2. Provide the information listed above.

3. The Help Desk will provide an ID number for adjudication.

Encontrar una farmacia de la red

Utilice uno de estos métodos fáciles para encontrar una farmacia de la red:

Visite a su local de

Walgreens

y

Rite Aid

Pharmacy.

Nos llame al:

866.599.5426

.

Utilice nuestro localizador de farmacias en linea:

www.tmesys.com

.

© 2011 PMSI, Inc. Todos los derechos reservados. C1257-1011-03 . .

Attention Pharmacists: Call 800.964.2531 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.

¿Preguntas? Llame al

1.866.599.5426

Need help in English?

(16)

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