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Express Scripts Prescription Form

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Express Scripts Prescription Form First Fill Temporary Prescription Services Card to be used effective January 15, 2013. 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 800-945-5951. 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 866-945-5951. Attention Supervisor: Please complete the following information for the injured worker. Express Scripts Employee Information ID #: SSN to be presented to the pharmacy at the time prescription is filled First M Last Date of Injury: / / Mailing Address MM/DD/CCYY Group #: Street Address or PO Box City State Zip Employee Date of Birth: / / Employer Name MM/DD/CCYY 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 Coborn's Gemmel Meijer RXD Tops Acme Pharmacy Costco Giant Minyard Safeway Ukrop's Albertson’s Cub Giant Eagle NCS HealthCare Sam’s Club United Drugs Albertson’s/Acme CVS Giant Foods Neighborcare Sav-On United Albertson’s/Osco D&W Hannaford Network Save Mart Supermarkets Albertson’s/Sav-On Dahl's Harris Teeter Pharmaceuticals Schnucks Vons Amerisource Dierbergs H-E-B Northeast Scolari's Waldbaums Bergen Discount Drugmart Hi-School Pharmacy Sedano Walgreens’ Anchor Pharmacies Doc's Drugs Pharmacy Services Shaw's Wal-Mart Arrow Dominicks Hy-Vee Osco Shop 'N Save Wegmans Aurora Drug Emporium Jewel/Osco P & C Food Shopko Weis Bartell Drugs Drug Fair Kash n Karry Markets ShopRite Winn Dixie Bigg's Drug Town Keltsch Pamida Snyder Bi-Lo Drug World Kerr Park Nicollet Stop & Shop Bi-Mart Eckerd Kmart Pathmark Sun Mart BJ’s Wholesale Econofoods Knight Drugs Pavilions Super Fresh Club EPIC Pharmacy Kroger Price Chopper Super Rx Brooks Network LeaderNet (PSAO) Publix Target Brookshire FamilyMeds Longs Drug Store Quality Markets Texas Oncology Brothers Farm Fresh Major Value Raley's Srvs Brookshire Grocery Farmer Jack Marsh Drugs Randalls The Pharm Bruno Food City Medic Discount Rite Aid Thrifty White Carrs Food Lion Medicap Rosauers Times Cash Wise Fred's Medistat Rx Express Tom Thumb NOTE: This form is not valid in the state of Ohio. For all other states, liability of a workers’ compensation claim is not assumed based on the dispensing of medication(s) to a patient. © 2011 Express Scripts, Inc. All Rights Reserved TEMPCARD 9.2010 .
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