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

13 

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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

Massachusetts state-mandated forms and a step-by-step process to follow in case 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 Melville, NY. 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 Massachusetts workers

compensation process.

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

1.

Massachusetts Form 101-Employer’s First Report of Injury or Fatality

This

form must be submitted to the Massachusetts Department of Industrial Accidents,

the carrier and the employee. It must be sent to the Department of Industrial

Accidents within seven (7) calendar days (not including Sunday and legal

holidays) from the fifth full or partial day the employee has been disabled. The

submission of this form does not constitute an admission of liability. Fines may be

imposed for three (3) of more violations within one (1) year.

2.

Directing Medical Care (not a state form)-

The employer has the right to

designate a health care provider for the first visit. After the first visit, the employee

has the right to choose their own health care provider.

3.

Massachusetts Form 127- Average Weekly Wage Computation Schedule-

Please submit this form to Tower Group Companies at the time 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

(2)

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

Massachusetts Form 101-Employer’s First Report of

Injury or Fatality

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.

(3)

The Commonwealth of Massachusetts

Department of Industrial Accidents – Department 101

600 Washington Street – 7th Floor, Boston, Massachusetts 02111

Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470

http://www.mass.gov/dia

EMPLOYER’S FIRST REPORT OF INJURY

OR FATALITY

THIS FORM MUST BE FILED BY THE

EMPLOYER

IN THE EVENT OF AN INJURY THAT RESULTS IN DEATH

OR FIVE OR MORE CALENDAR DAYS OF TOTAL OR PARTIAL INCAPACITY FROM EARNING WAGES.

INSTRUCTIONS AND CODES ON THE REVERSE SIDE

- Please Print Legibly or Type - Unreadable forms will be returned.

DIA USE ONLY

FORM 101

Form

101 -

Revised 8/2001 - Reproduce as needed.

THIS FORM DOES NOT CONSTITUTE AN EMPLOYEE’S CLAIM FOR BENEFITS UNDER WORKERS’ COMPENSATION.

1. Employee’s Name (Last, First, MI):

2. Home Telephone Number:

5. Home Address (No., Street, City, State & Zip Code):

8. Date of Hire (mm/dd/yyyy):

11. Employer’s Name:

12. Federal Tax I.D. Number:

13. Employer’s Address (No., Street, City, State & Zip Code):

16. Workers’ Compensation Insurance Carrier and Tel. No.

(NOT LOCAL AGENT/ADMINISTRATOR)

:

14. Employer’s Telephone Number:

20. DATE OF INJURY (mm/dd/yyyy):

21. Was Employee Injured on Employer’s Premises? Yes No

23. FIRST day of Total or Partial Incapacity to Earn Wages

(mm/dd/yyyy):

27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:

28. Person to Whom Injury was Reported (list position):

E

M

P

L

O

Y

E

E

3. Social Security Number*: 4. Sex:

M F

6. Marital Status:

M S

7. No. of Dependents:

9. Date of Birth (mm/dd/yyyy):

10. Average Weekly Wage:

Estimated Actual

$

E

M

P

L

O

Y

E

R

15. Industry Code (See Reverse Side):

17. W.C. Policy Number:

18. Self-Insured? Yes No

If Yes, Self-Insurer Number:

19. Business Type :

Service Wholesale Mfg.

Retail Other ________________________

I

N

J

U

R

Y

I

N

F

O

R

M

A

T

I

O

N

22. Location of Injury if not on Employer’s Premises:

25. If Employee has Died, Date of Death (mm/dd/yyyy):

24. FIFTH day of Total or Partial Incapacity to Earn Wages

(mm/dd/yyyy):

29. Date Reported (mm/dd/yyyy):

30. Date Reported as work related

(mm/dd/yyyy):

31. Injury Code(s)

a.

to body part

b.

to body part

c.

to body part

Body Part Code(s)

a.

b.

c.

32. Witness(es) to Injury - Give Full Name(s), if none state as such:

33. Has Employee Returned to Work? Yes No

34. Date Employee Returned to Work(mm/dd/yyyy):

35. Employee’s Regular Occupation:

36. Has Employee Returned to Regular Occupation: Yes No

37. EMPLOYER’S Name (SEE INSTRUCTIONS ON REVERSE SIDE):

38. Title:

39

.

EMPLOYER’S Signature (SEE INSTRUCTIONS ON REVERSE SIDE

):

40. Date Prepared (mm/dd/yyyy):

26. Source of Injury (Chemicals, Machinery, etc.):

(4)

EMPLOYER’S FIRST REPORT OF INJURY OR FATALITY

FILING INSTRUCTIONS

1. WHEN TO FILE: File this form within 7 calendar days, not including Sundays and legal holidays, of receipt of notice of any injury alleged to have arisen

out of and in the course of employment, which totally or partially incapacitates an employee for a period of 5 or more calendar days from earning wages.

This form is not an admission of liability, but must be filed even though the Employer may believe that the Employee is not injured, or that the Employee is

not entitled to benefits under M.G.L. Chapter 152.

2. WHERE TO FILE: This form should be mailed to the Department of Industrial Accidents at the address shown on the front of the form. Copies must also be

provided to the Employee and to the Employer’s Workers’ Compensation insurer.

3. PENALTIES: Failure to report injuries on this form may result in a fine of $100.00 in accordance with M.G.L. Chapter 152, Section 6.

4. EMPLOYER’S NAME & SIGNATURE IN BOXES 37 & 39: This form must be filed by the employer or an authorized agent/representative of the

employer.

Agriculture, Forestry and Fishing 01 Agriculture Production - Crops 02 Agriculture Production - Livestock 07 Agricultural Services 08 Forestry

09 Fishing, Hunting and Trapping Mining

10 Metal Mining 12 Coal Mining 13 Oil and Natural Gas

14 Nonmetallic Minerals, Except Fuels Construction

15 General Building Contractors 16 Heavy Construction, Ex. Building 17 Special Trade Contractors Manufacturing

20 Food and Kindred Products 21 Tobacco Products 22 Textile Mill Products

23 Apparel and Other Textile Products 24 Lumber and Wood Products 25 Furniture and Fixtures 26 Paper and Allied Products 27 Printing and Publishing

28 Chemicals and Allied Products 29 Petroleum and Coal Products 30 Rubber and Misc. Plastic Products 31 Leather and Leather Products 32 Stone, Clay and Glass Products 33 Primary Metal Industries 34 Fabricated Metal Products 35 Industrial Machinery and Equipment 36 Electronic and Other Electrical Equipment 37 Transportation Equipment

38 Instruments and Related Products 39 Miscellaneous Manufacturing Industries Transportation and Public Utilities 40 Railroad Transportation

41 Local and Interurban Passenger Transit 42 Trucking and Warehousing 43 U.S. Postal Service 44 Water Transportation 45 Transportation by Air 46 Pipelines, Except Natural Gas 47 Transportation Services 48 Communications

49 Electric, Gas and Sanitary Services Wholesale Trade

50 Wholesale Trade - Durable Goods

51 Wholesale Trade - Non-durable Goods Retail Trade

52 Building Materials and Garden Supplies 53 General Merchandizing

54 Food Stores

55 Automotive Dealers and Service Stations 56 Apparel and Accessory Stores 57 Furniture and Home Furnishing Stores 58 Eating and Drinking Establishments 59 Miscellaneous Retail

Finance, Insurance and Real Estate 60 Depository Institutions 61 Non-depository Institutions 62 Security and Commodity Brokers 63 Insurance Carriers

64 Insurance Agents, Brokers and Service 65 Real Estate

67 Holding and Other Investment Officers Services

70 Hotels and Other Lodging Places 72 Personal Services

73 Business Services

75 Auto Repair Services and Parking 76 Miscellaneous Repair Services

78 Motion Pictures

79 Amusements and Recreation Services 80 Health Services

81 Legal Services 82 Educational Services 83 Social Services

84 Museums, Botanical, Zoological Gardens 86 Membership Organizations

87 Engineering and Management Services 88 Private Households

89 Services, NEC Public Administration

91 Executive, Legislative and Garden 92 Justice, Public Order, and Safety 93 Finance, Taxation, and Monetary Benefits 94 Administration of Human Services 95 Environmental Quality and Housing 96 Administration of Economic Program 97 National Security and International Affairs Non-classifiable Establishments 99 Non-classifiable Establishments

NATURE OF INJURY OR ILLNESS CODES

100 Amputation or Erucloation 110 Asphyxia or Strangulation Etc. 120 Burns (Heat)

130 Burns (Chemical) 140 Concussion

160 Contusion, Crushing, Bruise 170 Cut, Laceration, Puncture 190 Dislocation

200 Electric Shock, Electrocution 210 Fracture 250 Hernia, Rupture 300 Scratches, Abrasions 310 Sprains, Strains 400 Multiple Injuries 900 No Injury

950 Damage to Prosthetic Devices 995 No Other Injury, NEC** 999 Non-classifiable

Infective or Parasitic Disease 150 Infective or Parasitic Disease, UNS* 151 Amebiasis

152 Anthrax 153 Brucellosis

154 Conjunctivitis and Opthalmia 156 Tetanus

BODY PART AFFECTED CODES

157 Tuberculosis

159 Other Infective or Parasitic Diseases Dermatitis

180 Dermatitis, UNS* 183 Primary Infections of the Skin 184 Other Skin Conditions 185 Dermatitis, Allergenic or Contact 189 Skin Condition, NEC**

Poisoning Systemic 270 Poisoning, Systemic, UNS* 271 Due to Toxic Materials other than Lead 272 Diseases of the Blood and Blood Forming Organs

273 Upper Respiratory Conditions 274 Influenza, Pneumonia, Etc. 276 Other Diseases of the Gastro-Intestinal Tract

278 Effects of Lead

279 Other Toxic Effects of One System Only Respiratory Systems, Conditions of 570 Respiratory Systems, Conditions of 571 Upper Respiratory

572 Asthma, Influenza, Pneumonia Pneumoconiosis 280 Pneumoconiosis 281 Aluminosis 282 Anthracosis 283 Asbestosis 284 Byssinosis 285 Siderosis 286 Silicosis 287 Other Pneumoconioses 289 Pneumoconiosis and Tuberculosis

Nervous System, Conditions of 560 Nervous System, Conditions of - NEC** 561 Diseases of the Central Nervous System

562 Diseases of the Nerves and Peripheral Ganglia

Neoplasm Tumor 550 Neoplasm Tumor, UNS* 551 Malignant

552 Benign Radiation Effects 290 Radiation Effects, UNS* 291 Non-Ionizing Radiation 292 Microwaves

293 Ionizing Radiation - X-Ray 294 Ionizing Radiation - Isotopes 295 Welder’s Flash

Other

265 Carpal Tunnel Syndrome 510 Cardiovascular and Other Conditions of the Circulatory System

520 Complications Peculiar to Medical Care 500 Effects of Changes in Atmospheric Pressure

240 Effects of Environmental Heat 220 Effects of Exposure to Low Temperature 530 Eye, other Diseases of the Eye 230 Hearing Loss or Impairment 991 Heart Condition ,Excludes Heart Attack 320 Hemorrhoids

330 Hepatitis, Serum and Infective 275 Hepatitis, Toxic

260 Inflammation of Joints, Etc. 540 Mental Disorders 900 No Illness 999 Non-classifiable 990 Occupational Disease, NEC** 580 Symptoms and Ill-defined Conditions

Head 100 Head, UNS* 110 Brain 120 Ear(s), UNS* 121 Ear(s), External 124 Ear(s), Internal 130 Eye(s), UNS* 140 Face, UNS* 141 Jaw, Chin

144 Mouth and Throat (vocal chords, larynx) 146 Nose

148 Face, Multiple Parts 149 Face, NEC** 150 Scalp

160 Skull 198 Head Multiple 200 Neck & Cervical Vertebrae UPPER EXTREMITIES 300 Upper Extremities, NEC** 310 Arm(s), UNS* 311 Upper Arm 313 Elbow(s) 315 Forearm(s) 318 Arm(s), Multiple 319 Arm(s), NEC** 320 Wrist(s)

330 Hand(s), Not Wrists or Fingers 340 Finger(s)

398 Upper Extremities, Multiple 400 Trunk, UNS* 410 Abdomen, Internal Organs,

Inguinal Hernia 420 Back

430 Chest, Ribs, Breastbone, Internal Organs 440 Hip(s)..,Pelvis, Organs and Buttocks 450 Shoulder(s) 498 Trunk, Multiple LOWER EXTREMITIES 500 Lower Extremities 510 Leg(s), UNS*

INDUSTRY CODES

*UNS - UNSPECIFIED

**NEC - NOT ELSEWHERE CLASSIFIED

513 Knee(s) 515 Lower Leg(s) 518 Leg(s), Multiple 519 Leg(s), NEC** 520 Ankle(s)

530 Foot or Feet, Not Ankle 540 Toe(s)

598 Lower Extremities, Multiple 700 MULTIPLE PARTS

Applies when more than one major body part as been effected such as an arm and a leg 999 NON-CLASSIFIABLE - Insufficient

mation to identify part of body effected. In-cludes damage to prosthetic devises.

(5)

DIA USE ONLY

Make any comments on the reverse side of this form or on a separate sheet.

Form 127 - Created 8/2005

Reproduce as needed.

AVERAGE WEEKLY WAGE COMPUTATION SCHEDULE

Indicate only those wages earned by the injured worker during the 52 week period immediately preceding the accident. If the injured

employee has worked for less than 52 weeks, report wages from the time worked and, for the remaining weeks on this schedule,

substitute wages of a fellow employee in the same class of employment who has worked for one year or more.

16. Date Signed (mm/dd/yyyy):

The Commonwealth of Massachusetts

Department of Industrial Accidents

1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017

Info. Line 800 323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470

http://www.mass.gov/dia

FORM 127

Print or Type

1. Employer’s Name and Address:

4. Employee’s Name and Address:

8. Date of Disability (mm/dd/yyyy):

7. Date of Injury (mm/dd/yyyy):

2. Insurer’s Case File #:

5. # of dependent children:

6. # of other dependents:

3. DIA Board # (if known):

9. Date of Employment (mm/dd/yyyy):

10. Has employee been certified by U.S. Veterans Administration for any type of disability? Yes No

11.

Week

No.

Year:

Week Ending

Month Day

Year:

Week Ending

Month Day

Gross Amount

Before Taxes

Gross Amount

Before Taxes

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

Week

No.

Year:

Week Ending

Month Day

Gross Amount

Before Taxes

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

Week

No.

Total:

12. Was room furnished to the employee?

Yes No

13. If tips or other benefits were earned, describe and state value per week:

THIS IS A TRUE COPY OF THE PAYROLL RECORD OF THE ABOVE NAMED EMPLOYEE OR FELLOW EMPLOYEE IN THE SAME CLASS OF EMPLOYEMENT

14. Name of Fellow Employee (if

applicable):

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(7)

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

(8)

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.

(9)

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.

(10)

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

(11)

(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

(12)

(

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?

(13)

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