Temporary Prescription Services

Attention Injured Worker  On your first visit, please give this notice to any pharmacy listed below to expedite the processing of your approved workers’ compensation prescriptions. (Based on the established parameters by your employer.)  Questions or Need Assistance Locating a Participating Pharmacy: Call the Express Scripts Contact Center at 888.786.9640. Atencion Trabajador Lesionado:  Este formulario de identificación para servicios temporales de prescripción de recetas por compensación del trabajador DEBERÁ SER PRESENTADO a su farmacéutico al surtir su(s) receta(s) inicial(es).  Si tiene cualquier duda o necesita localizar una farmacia participante, por favor contacte al área de Atención a Clientes de Express Scripts, en el teléfono 888.786.9640. Attention Supervisor: Please complete the following information for the injured worker. Express Scripts Employee Information

SSN to be presented to the pharmacy at the time prescription is filled ID #: First M Last

Date of Injury: / / Mailing Address MM/DD/CCYY Street Address or PO Box Group #: G5VA

City State Zip Employee Date of Birth: / / MM/DD/CCYY Employer’s Name

Attention Pharmacist  Express Scripts administers this workers’ compensation prescription program. Follow the steps below to submit a claim.  For assistance, call the Express Scripts Contact Center at 888.786.9640.

Pharmacy Processing Steps Step 1 Enter bin number 003858 Step 2 Enter processor control A4 Step 3 Enter the group number as it appears above Step 4 Enter the injured worker’s 9 digit ID# Step 5 Enter first name & last name Step 6 Enter the injured worker’s date of injury (enter in PA field in the format ccyymmdd) Participating Pharmacy Chains A & P CVS Hannaford Northeast Pharmacy Services Shopko Acme Pharmacy D&W Happy Harry's Osco ShopRite Albertson’s Dahl's Harris Teeter P & C Food Markets Snyder Albertson’s/Acme Dierbergs H-E-B Pamida Star Markets Albertson’s/Osco Discount Drugmart Hi-School Pharmacy Park Nicollet Stop & Shop Albertson’s/Sav-On Doc's Drugs Hy-Vee Pathmark Sun Mart AmerisourceBergen Dominicks Jewel/Osco Pavilions Super Fresh Anchor Pharmacies Drug Emporium Kash n Karry Price Chopper Target Arrow Drug Fair Keltsch Publix Texas Oncology Services Aurora Drug Town Kerr Quality Markets The Pharm Bartell Drugs Drug World Kmart Raley's Thrifty White Bigg's Duane Reade Knight Drugs Randalls Times Bi-Lo Eckerd LeaderNet (PSAO) Rite Aid Tom Thumb Bi-Mart Econofoods Longs Drug Store Rosauers Tops BJ’s Wholesale Club EPIC Pharmacy Network Major Value Rx Express Ukrop's Brooks FamilyMeds Marsh Drugs RXD United Drugs Brookshire Brothers Farm Fresh Medic Discount Safeway United Supermarkets Brookshire Grocery Farmer Jack Medicap Sam’s Club Vons Bruno Food City Medistat Sav-On Waldbaums Carrs Food Lion Meijer Save Mart Walgreens Cash Wise Fred's Minyard Schnucks Wal-Mart Coborn's Gemmel NCS HealthCare Scolari's Wegmans Costco Giant Neighborcare Sedano Weis Cub Giant Eagle Network Pharmaceuticals Shaw's Winn Dixie Giant Foods Shop 'N Save

TEMPCARD 8.2008