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
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
.
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.
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.):
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.
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):
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
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.
•
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.
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
(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
(
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?
