First Fill Temporary Pharmacy Card Making It Easy to Get Your Workers’ Compensation Prescriptions Filled

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First Fill Temporary Pharmacy Card Making it easy to get your workers’ compensation prescriptions filled.

Employer: Print this page immediately upon receiving notice of injury, fill in the information below and give it to your employee.

Injured Employee: 1. If you need a prescription filled for a work-related injury or illness, go to a Tmesys network pharmacy. 2. Give this page to the pharmacist. 3. The pharmacist will fill your prescription at no cost.

Attention Pharmacists: Call 800.964.2531 to establish First Fill benefit eligibility and obtain the ID# for online adjudication Prescription Card of approved benefits for the injured worker. CARRIER/TPA EMPLOYER/OTHER ENTITY Tmesys is the designated PBM for this patient. Sedgwick CLIC

INJURED WORKER NAME Tmesys Pharmacy

SOCIAL SECURITY NUMBER DATE OF INJURY Help Desk 800.964.2531 Please provide directly to Pharmacist

Notice to Cardholder: This card should be presented to your pharmacy to receive NDC Envoy medication for your work-related injury. It is only valid within 30 days of your date of injury. RxBin 004261 or 002538 For information regarding the program or to find nearby pharmacies call 866.599.5426. RxPCN CAL or Envoy Acct. #

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

Finding a Network Pharmacy Use one of these easy methods to find a network pharmacy: ■ Visit one of the following pharmacy chains: Walgreens Walmart Duane Reade Publix

Rite Aid CVS Kroger Safeway

■ Use our pharmacy locator online: www.pmsionline.com/pharmacy-center. ■ Call us: 866.599.5426

Tmesys Retail Pharmacy Network* More than 65,000 pharmacies, including large chains and many neighborhood independent pharmacies, meaning that your prescription can be filled at most pharmacies nationwide.

Accredo Health Group Food 4 Less Pharmacy Lowes Marketplace Sam’s Pharmacy Anchor Pharmacy Food City Pharmacy Marc’s Pharmacy Save Mart Pharmacy Arrow Prescription Food Lion Pharmacy Marsh Drugs Save-Rite Pharmacy Center Food Town Pharmacy Martin’s Pharmacy Schnucks Pharmacy Aurora Pharmacy Food World Pharmacy May’s Drug Store Scolaris Pharmacy Baker’s Pharmacy Fred Meyer Pharmacy Med-Fast Pharmacy Sedanos Pharmacy & Bartell Drugs Fred’s Pharmacy Medical Arts Pharmacy Discount Bashas’ United Drug Fruth Pharmacy Medicap Pharmacy Shaw’s Pharmacy Bel Air Pharmacy Fry’s Pharmacy Medicine Shoppe Shaws/Osco Pharmacy Big Y Pharmacy Gemmel Pharmacy Pharmacy (various) Shop ’n Save Pharmacy Biggs Pharmacy Gentiva Health Services Med-X Drug Shopko Pharmacy Bi-Lo Genuardi’s Pharmacy Meijer Pharmacy Shoppers Pharmacy Bi-Mart Gerbes Pharmacy Minyard Pharmacy ShopRite Pharmacy Bioscrip Pharmacy Giant Eagle Pharmacy Morton Pharmacy Snyder Drug Emporium BJ’s Pharmacy Giant Pharmacy Mr. Discount Drugs Southern Family Market Brookshire’s Pharmacy Glen’s Pharmacy Navarro Discount Star Pharmacy Bruno’s Pharmacy Good Day Pharmacy Pharmacies Stop & Shop Pharmacy Buehler’s Pharmacy Grand Union Pharmacy NeighborCare Pharmacy Sunscript Pharmacy Caremark Pharmacy Gristedes Pharmacy No Frills Pharmacy Super 1 Pharmacy Carle Rx Express H-E-B Pharmacy Network Pharmacy Super D Carrs Quality Center Haggen Foods Owens Pharmacy Super G City Market Pharmacy Hannaford P&C Food & Pharmacy Super Foodmart Clinic Pharmacy Happy Harry’s Pamida Pharmacy Pharmacy Coborn’s/Cash Wise Harmons Pharmacy Park Nicollet Pharmacy Super Fresh Pharmacy Concord Drugs Harps Pharmacy Pathmark Pharmacy Super Rx Pharmacy Costco Pharmacy Harris Teeter Pavilions Pharmacy Sweetbay Cub Pharmacy Hartig Drug PharmaCare Pharmacy The Pharm CVS Pharmacy Harvest Foods Pharmacy Pharmacy Express Thriftway Drugs D&W Pharmacy Harveys Supermarket Pharmacy Plus Thrifty White Drug Dahl’s Pharmacy Pharmacy Pick ’N Save Pharmacy Times Pharmacy Dierbergs Hen House Pharmacy Piggly Wiggly Tom Thumb Pharmacy Dillon Pharmacy Hi-School Pharmacy PrairieStone Pharmacy Tops Pharmacy Discount Drug Mart Homeland Pharmacy Price Chopper Pharmacy U-Save Pharmacy Doc’s Drug Hometown Pharmacy Price Cutter Pharmacy Ukrops Pharmacy Dominick’s Finer Foods Hy-Vee Pharmacy Publix Pharmacy United Pharmacy Drug Emporium Ingles Pharmacy Q Pharmacy USA Drug Drug Mart Kmart Pharmacy QFC Pharmacy Vix Pharmacy Drug Town Kerr Drug Quality Markets Vons Pharmacy Drug Warehouse King Kullen Pharmacy Pharmacy VG’s Pharmacy Drugs For Less King Soopers Pharmacy QuickChek Pharmacy Waldbaum’s Pharmacy E. W. James Pharmacy Kings Pharmacy QVL Pharmacy Walgreens Eagle Pharmacy Kinney Drugs Rainbow Pharmacy Wal-Mart Pharmacy Eaton Apothecary Klingensmith’s Raley’s Drug Center Wegman Pharmacy Econofoods Pharmacy Knight Drugs Ralphs Pharmacy Weis Pharmacy Edwards Pharmacy Kohl’s Pharmacy Randalls Pharmacy White Drug Fagen Pharmacy Kohll’s Pharmacy Reasors Pharmacy Winn-Dixie Family Drug Store Kopp Drug Rite Aid Pharmacy Yokes Pharmacy Family Fare Pharmacy Kroger Pharmacy Ritzman Natural Health Family Pharmacy Lewis Pharmacy Rosauers Pharmacy Familymeds Pharmacy Lifechek Drug RXD Pharmacy Farm Fresh Pharmacy Longs Drug Sack ’n Save Pharmacy Farmer Jack Pharmacy Louis and Clark Safeway Pharmacy

*List subject to change. This is a partial listing only.