Sedgwick Claims Kit
Pennsylvania
P.O. Box 14779 | Lexington, KY 40512 | Toll Free: 866-738-9201 | Fax: 859-280-3275
Dear Insured:
We would like to welcome you as a policyholder of Southern Insurance Company.
Sedgwick is your Claims Administrator and we are pleased to be able to provide you
with workers’ compensation claims handling services. Please follow the below
instructions for filing a new claim and note the claim kit attachment.
Where do I report a claim?
 Phone:
 Email:
 Fax:
855-728-5277 (855-7ATLAS7) OR;
[email protected] OR:
866-383-3296
Where do I send my injured employee for medical treatment?
 Website:
www.sedgwickproviders.com/AG
Sedgwick Claim Kit Attachments:
•
•
•
Employer Posting Notice (LIBC-500)
Atlas General First Fill Temporary Pharmacy Card
Atlas General Pharmacy Card
Need a loss run?
 Email us:
[email protected]
Have more questions?
Contact the Atlas Customer Care Team at Sedgwick - One of our friendly Client Services
Associates will be happy to assist you.
 Phone:
866-738-9201
 Email:
[email protected]
We appreciate your business and believe that communication is critical for successful
claims administration. We encourage you to contact us if you have any questions.
www.Atlas.us.com/claims
PENNSYLVANIA Welcome Letter – Southern Insurance Co. 7/2014
REMEMBER:
It is Important to Tell Your
Employer about Your Injury
The name, address and telephone number of your employer’s workers’ compensation insurance company, third-party
administrator (TPA), or person handling workers’ compensation claims for your company, are shown below.
Employer Name:
Date Posted:
IF INSURED:
(Complete all applicable spaces)
IF SOMEONE OTHER THAN INSURER IS
HANDLING CLAIMS:
(Complete all applicable spaces)
Name of Insurance Company:
Name of TPA (Claims administrator):
Address:
Address:
Telephone Number:
Telephone Number:
Insurer’s Bureau Code:
IF SELF-INSURED:
(Complete all applicable spaces)
IF SOMEONE OTHER THAN SELF-INSURER
IS HANDLING CLAIMS:
(Complete all applicable spaces)
Name of person handling claims at
Name of TPA (Claims administrator):
the self-insured:
Address:
Address:
Telephone Number:
Telephone Number:
Self-Insured Bureau Code:
Department of Labor & Industry | Bureau of Workers’ Compensation | 1171 S. Cameron Street, Room 103 | Harrisburg, PA 17104-2501
717.772.0621 | www.dli.state.pa.us
LIBC-500 REV 5-09
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
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
of approved benefits for the injured worker.
Prescription Card
CARRIER/TPA
Sedgwick
EMPLOYER/OTHER ENTITY
Atlas General Insurance
Tmesys is the designated PBM for this patient.
INJURED WORKER NAME
Tmesys Pharmacy
Help Desk 800.964.2531
DATE OF INJURY
SOCIAL SECURITY NUMBER
Please provide directly to Pharmacist
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.
RxBin
RxPCN
NDC
Envoy
004261 or 002538
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:
Duane Reade
Walmart
Walgreens
Kroger
CVS
Rite Aid
■
■
Publix
Safeway
Use our pharmacy locator online: www.pmsionline.com/pharmacy-center.
Call us: 866.599.5426
© 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
.
Tmesys Retail Pharmacy Network*
More than 60,000 pharmacies, including large chains and many neighborhood
independent pharmacies, meaning that your prescription can be filled at most
pharmacies nationwide.
Accredo Health Group
Anchor Pharmacy
Arrow Prescription
Center
Aurora Pharmacy
Baker’s Pharmacy
Bartell Drugs
Bashas’ United Drug
Bel Air Pharmacy
Big Y Pharmacy
Biggs Pharmacy
Bi-Lo
Bi-Mart
Bioscrip Pharmacy
BJ’s Pharmacy
Brookshire’s Pharmacy
Bruno’s Pharmacy
Buehler’s Pharmacy
Caremark Pharmacy
Carle Rx Express
Carrs Quality Center
City Market Pharmacy
Clinic Pharmacy
Coborn’s/Cash Wise
Concord Drugs
Costco Pharmacy
Cub Pharmacy
CVS Pharmacy
D&W Pharmacy
Dahl’s Pharmacy
Dierbergs
Dillon Pharmacy
Discount Drug Mart
Doc’s Drug
Dominick’s Finer Foods
Drug Emporium
Drug Mart
Drug Town
Drug Warehouse
Drugs For Less
E. W. James Pharmacy
Eagle Pharmacy
Eaton Apothecary
Econofoods Pharmacy
Edwards Pharmacy
Fagen Pharmacy
Family Drug Store
Family Fare Pharmacy
Family Pharmacy
Familymeds Pharmacy
Farm Fresh Pharmacy
Farmer Jack Pharmacy
Food 4 Less Pharmacy
Food City Pharmacy
Food Lion Pharmacy
Food Town Pharmacy
Food World Pharmacy
Fred Meyer Pharmacy
Fred’s Pharmacy
Fruth Pharmacy
Fry’s Pharmacy
Gemmel Pharmacy
Gentiva Health Services
Genuardi’s Pharmacy
Gerbes Pharmacy
Giant Eagle Pharmacy
Giant Pharmacy
Glen’s Pharmacy
Good Day Pharmacy
Grand Union Pharmacy
Gristedes Pharmacy
H-E-B Pharmacy
Haggen Foods
Hannaford
Happy Harry’s
Harmons Pharmacy
Harps Pharmacy
Harris Teeter
Hartig Drug
Harvest Foods Pharmacy
Harveys Supermarket
Pharmacy
Hen House Pharmacy
Hi-School Pharmacy
Homeland Pharmacy
Hometown Pharmacy
Hy-Vee Pharmacy
Ingles Pharmacy
Kmart Pharmacy
Kerr Drug
King Kullen Pharmacy
King Soopers Pharmacy
Kings Pharmacy
Kinney Drugs
Klingensmith’s
Knight Drugs
Kohl’s Pharmacy
Kohll’s Pharmacy
Kopp Drug
Kroger Pharmacy
Lewis Pharmacy
Lifechek Drug
Longs Drug
Louis and Clark
Lowes Marketplace
Marc’s Pharmacy
Marsh Drugs
Martin’s Pharmacy
May’s Drug Store
Med-Fast Pharmacy
Medical Arts Pharmacy
Medicap Pharmacy
Medicine Shoppe
Pharmacy (various)
Med-X Drug
Meijer Pharmacy
Minyard Pharmacy
Morton Pharmacy
Mr. Discount Drugs
Navarro Discount
Pharmacies
NeighborCare Pharmacy
No Frills Pharmacy
Network Pharmacy
Owens Pharmacy
P&C Food & Pharmacy
Pamida Pharmacy
Park Nicollet Pharmacy
Pathmark Pharmacy
Pavilions Pharmacy
PharmaCare Pharmacy
Pharmacy Express
Pharmacy Plus
Pick ’N Save Pharmacy
Piggly Wiggly
PrairieStone Pharmacy
Price Chopper Pharmacy
Price Cutter Pharmacy
Publix Pharmacy
Q Pharmacy
QFC Pharmacy
Quality Markets
Pharmacy
QuickChek Pharmacy
QVL Pharmacy
Rainbow Pharmacy
Raley’s Drug Center
Ralphs Pharmacy
Randalls Pharmacy
Reasors Pharmacy
Rite Aid Pharmacy
Ritzman Natural Health
Rosauers Pharmacy
RXD Pharmacy
Sack ’n Save Pharmacy
Safeway Pharmacy
Sam’s Pharmacy
Save Mart Pharmacy
Save-Rite Pharmacy
Schnucks Pharmacy
Scolaris Pharmacy
Sedanos Pharmacy &
Discount
Shaw’s Pharmacy
Shaws/Osco Pharmacy
Shop ’n Save Pharmacy
Shopko Pharmacy
Shoppers Pharmacy
ShopRite Pharmacy
Snyder Drug Emporium
Southern Family Market
Star Pharmacy
Stop & Shop Pharmacy
Sunscript Pharmacy
Super 1 Pharmacy
Super D
Super G
Super Foodmart
Pharmacy
Super Fresh Pharmacy
Super Rx Pharmacy
Sweetbay
The Pharm
Thriftway Drugs
Thrifty White Drug
Times Pharmacy
Tom Thumb Pharmacy
Tops Pharmacy
U-Save Pharmacy
Ukrops Pharmacy
United Pharmacy
USA Drug
Vix Pharmacy
Vons Pharmacy
VG’s Pharmacy
Waldbaum’s Pharmacy
Walgreens
Wal-Mart Pharmacy
Wegman Pharmacy
Weis Pharmacy
White Drug
Winn-Dixie
Yokes Pharmacy
*List subject to change. This is a partial listing only.
© 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
Tarjeta temporal
para surtir por primera vez sus recetas en farmacias
Facilita la tarea de surtir las recetas correspondientes a la compensación por accidentes o
enfermedades laborales.
Empleador:
Imprima esta página inmediatamente después de recibir un aviso de lesión, complete
la información que se encuentra a continuación y entréguesela a su empleado.
Empleado lesionado:
1. Si necesita que se le surta una receta por una lesión o enfermedad relacionada con
el trabajo, diríjase a una farmacia de la red Tmesys.
2. Entréguele esta página al farmacéutico.
3. El farmacéutico le surtirá la receta sin costo alguno.
At. farmacéuticos: Llamen al 800.964.2531 a fin de establecer la elegibilidad para el beneficio de surtir por primera vez su receta y obtener el
número de ID para la adjudicación en línea de los beneficios aprobados
para el trabajador lesionado.
Prescription Card
COMPAÑÑÍA DE SEGUROS/ADMINISTRADOR EXTERNO (TPA)
EMPLEADOR/OTRA ENTIDAD
Sedgwick
Atlas General Insurance
Tmesys es la administradora de beneficios de farmacia (PBM) asignada a
este paciente.
NOMBRE DEL EMPLEADO LESIONADO
NÚMERO DE SEGURO SOCIAL
FECHA EN QUE OCURRIÓ LA LESIÓN
Entregar directamente al farmacéutico
Aviso al titular de la tarjeta: Para recibir los medicamentos correspondiente a la
lesión laboral sufrida, debe presentarle esta tarjeta al farmacéutico. Solo es válida durante
30 días a partir de la fecha de la lesión. Para obtener información sobre el programa o para
encontrar farmacias cercanas a usted, llame al 866.599.5426
RxBin
RxPCN
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct. #
(Si desea llevar la tarjeta en la billetera, corte a lo largo de la línea exterior y dóblela por la mitad)
Farmacéutico:
1. Llame al servicio de asistencia de farmacias de Tmesys al 800.964.2531.
2. Suministre la información que figura arriba.
3. El servicio de asistencia le dará un número de ID correspondiente a la adjudicación.
Cómo encontrar una farmacia de la red
Para encontrar una farmacia de la red, use uno de estos sencillos métodos:
■
Visite alguna de las siguientes cadenas de farmacias:
Walgreens
Rite Aid
Walmart
CVS
Duane Reade
Kroger
Publix
Safeway
■
Use nuestro localizador de farmacias en línea: www.pmsionline.com/pharmacy-center.
■
Llámenos: 866.599.5426
© 2013 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
Red de farmacias minoristas de Tmesys* Más de 65,000 farmacias, entre ellas grandes
cadenas, así como farmacias independientes, lo cual permite que le puedan surtir sus recetas en la mayoría de farmacias del país.
Accredo Health Group
Anchor Pharmacy
Arrow Prescription Center
Aurora Pharmacy
Baker’s Pharmacy
Bartell Drugs
Bashas’ United Drug
Bel Air Pharmacy
Big Y Pharmacy
Biggs Pharmacy
Bi-Lo
Bi-Mart
Bioscrip Pharmacy
BJ’s Pharmacy
Brookshire’s Pharmacy
Bruno’s Pharmacy
Buehler’s Pharmacy
Caremark Pharmacy
Carle Rx Express
Carrs Quality Center
City Market Pharmacy
Clinic Pharmacy
Coborn’s/Cash Wise
Concord Drugs
Costco Pharmacy
Cub Pharmacy
CVS Pharmacy
D&W Pharmacy
Dahl’s Pharmacy
Dierbergs
Dillon Pharmacy
Discount Drug Mart
Doc’s Drug
Dominick’s Finer Foods
Drug Emporium
Drug Mart
Drug Town
Drug Warehouse
Drugs For Less
E. W. James Pharmacy
Eagle Pharmacy
Eaton Apothecary
Econofoods Pharmacy
Edwards Pharmacy
Fagen Pharmacy
Family Drug Store
Family Fare Pharmacy
Family Pharmacy
Familymeds Pharmacy
Farm Fresh Pharmacy
Farmer Jack Pharmacy
Food 4 Less Pharmacy
Food City Pharmacy
Food Lion Pharmacy
Food Town Pharmacy
Food World Pharmacy
Fred Meyer Pharmacy
Fred’s Pharmacy
Fruth Pharmacy
Fry’s Pharmacy
Gemmel Pharmacy
Gentiva Health Services
Genuardi’s Pharmacy
Gerbes Pharmacy
Giant Eagle Pharmacy
Giant Pharmacy
Glen’s Pharmacy
Good Day Pharmacy
Grand Union Pharmacy
Gristedes Pharmacy
H-E-B Pharmacy
Haggen Foods
Hannaford
Happy Harry’s
Harmons Pharmacy
Harps Pharmacy
Harris Teeter
Hartig Drug
Harvest Foods Pharmacy
Harveys Supermarket Pharmacy
Hen House Pharmacy
Hi-School Pharmacy
Homeland Pharmacy
Hometown Pharmacy
Hy-Vee Pharmacy
Ingles Pharmacy
Kmart Pharmacy
Kerr Drug
King Kullen Pharmacy
King Soopers Pharmacy
Kings Pharmacy
Kinney Drugs
Klingensmith’s
Knight Drugs
Kohl’s Pharmacy
Kohll’s Pharmacy
Kopp Drug
Kroger Pharmacy
Lewis Pharmacy
Lifechek Drug
Longs Drug
Louis and Clark
Lowes Marketplace
Marc’s Pharmacy
Marsh Drugs
Martin’s Pharmacy
May’s Drug Store
Med-Fast Pharmacy
Medical Arts Pharmacy
Medicap Pharmacy
Medicine Shoppe Pharmacy
(various)
Med-X Drug
Meijer Pharmacy
Minyard Pharmacy
Morton Pharmacy
Mr. Discount Drugs
Navarro Discount Pharmacies
NeighborCare Pharmacy
No Frills Pharmacy
Network Pharmacy
Owens Pharmacy
P&C Food & Pharmacy
Pamida Pharmacy
Park Nicollet Pharmacy
Pathmark Pharmacy
Pavilions Pharmacy
PharmaCare Pharmacy
Pharmacy Express
Pharmacy Plus
Pick ’N Save Pharmacy
Piggly Wiggly
PrairieStone Pharmacy
Price Chopper Pharmacy
Price Cutter Pharmacy
Publix Pharmacy
Q Pharmacy
QFC Pharmacy
Quality Markets Pharmacy
QuickChek Pharmacy
QVL Pharmacy
Rainbow Pharmacy
Raley’s Drug Center
Ralphs Pharmacy
Randalls Pharmacy
Reasors Pharmacy
Rite Aid Pharmacy
Ritzman Natural Health
Rosauers Pharmacy
RXD Pharmacy
Sack ’n Save Pharmacy
Safeway Pharmacy
Sam’s Pharmacy
Save Mart Pharmacy
Save-Rite Pharmacy
Schnucks Pharmacy
Scolaris Pharmacy
Sedanos Pharmacy
Shaw’s Pharmacy
Shaws/Osco Pharmacy
Shop ’n Save Pharmacy
Shopko Pharmacy
Shoppers Pharmacy
ShopRite Pharmacy
Snyder Drug Emporium
Southern Family Market
Star Pharmacy
Stop & Shop Pharmacy
Sunscript Pharmacy
Super 1 Pharmacy
Super D
Super G
Super Foodmart Pharmacy
Super Fresh Pharmacy
Super Rx Pharmacy
Sweetbay
The Pharm
Thriftway Drugs
Thrifty White Drug
Times Pharmacy
Tom Thumb Pharmacy
Tops Pharmacy
U-Save Pharmacy
Ukrops Pharmacy
United Pharmacy
USA Drug
Vix Pharmacy
Vons Pharmacy
VG’s Pharmacy
Waldbaum’s Pharmacy
Walgreens
Wal-Mart Pharmacy
Wegman Pharmacy
Weis Pharmacy
White Drug
Winn-Dixie
Yokes Pharmacy
*Lista sujeta a cambios. Ésta es sólo una lista
Prescription Card
«DOI»
DOI
«subID»
ID#
Name «Patientname»
Carrier «Carrier»
P.O. Box 152539
Tampa, FL 33684-2539
Prescription Card
«DOI»
DOI
«subID»
ID#
Name «Patientname»
Carrier «Carrier»
PERSONAL & CONFIDENTIAL
Important Insurance Claim Document Enclosed
Questions?
Prescription Delivery By Mail
In addition to providing access to your medications at a local pharmacy, Tmesys
can also deliver your medications to your home through our PMSI Mail Order
program at no cost. Using this convenient program means you will not have to
drop off or pick up your prescription or wait in line while it is being ¿lled.
For more information or to sign up, call 1.800.304.1764 or go to
www.pmsionline.com/pharmacy-center, click on Mail Order Overview.
Prescription Card
¿Necesitas ayuda en español?
Llame al 1.866.599.5426
NDC
RxBin
004261
or
CAL
or
RxPCN
Issuer (80840) 9151014609
Injury Date «DOI»
«subID»
ID#
«Patientname»
Name
Carrier/TPA «Carrier»
Envoy
002538
Envoy Acct.#
1.866.599.5426
RxBin
RxPCN
Issuer (80840)
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct.#
9151014609
Attention Pharmacist: Tmesys is the workers’
compensation PBM for this patient. For questions
regarding transmission, call 1.800.964.2531.
RxBin
RxPCN
Issuer (80840)
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct.#
9151014609
Note: Your use of this card is limited to those prescriptions
medically related to an injury that is considered to be covered
under the applicable state workers’ compensation law.
Attention Pharmacist: Tmesys is the designated
workers’ compensation PBM for this patient. Call Tmesys
with questions regarding transmission or rejection at:
1.800.964.2531.
Attention Cardholder: For questions regarding coverage
or to ¿nd a pharmacy call Tmesys at: 1.866.599.5426
or visit www.tmesys.com.
IMPORTANT: ONCE CARDS HAVE BEEN REMOVED PLEASE RETAIN THIS PORTION FOR YOUR RECORDS
Attention Pharmacist: Tmesys is the workers’
compensation PBM for this patient. For questions
regarding transmission, call 1.800.964.2531.
Taking Care of
<<PATIENTNAME>>
Using the Pharmacy Card
We want to make it easy for you to obtain the medication you need to recover from your
work-related injury. Just follow these steps:
1. Activate the card by calling the toll-free number.
2. Separate the attached cards and place one in your wallet and one on your key ring.
3. Give a card to the pharmacist next time you have a new prescription or refill.
4. Your prescription will be filled at no cost.
Finding a Pharmacy
You can use any pharmacy that is part of the Tmesys network to ¿ll your prescription—and
with over 60,000 locations, the card is accepted at most pharmacies nationwide. Finding
a network pharmacy is simple! Use one of the options below:
Ŷ Visit one of the following pharmacy chains:
Walgreens
Rite Aid
Walmart
Target
Duane Reade
Kroger
Publix
Safeway
Ŷ Go to one of these nearby pharmacies:
«Pharmacy1»
«Pharmacy2»
«Pharmacy3»
Ŷ Look up a pharmacy on the website: www.tmesys.com, click on Pharmacy Locator
and choose a search option.
Ŷ Call us toll free at 1.866.599.5426.
© 2011 PMSI, Inc. All Rights Reserved. SCMSMOD