ࡱ> '` bjbj{P{P 9::x.x.x.x.$.=t0t0t0t0t0222<<<<<<<$>h|@p<21"222<t0t0<O5O5O52t0t0<O52<O5O5O5t0h0 TJ݇x.4.O55<0=O5A4FAO5AO5822O522222<<E5 222=2222)x.x. Chartis Insurance Injured Workers Prescription Information Sheet TAKE TO PHARMACY Injured Worker Name:_____________________________________Social Security #:_______________________________Date Of Injury:_______________ Dear Injured Worker, On your first visit, please give this notice to any pharmacy listed on this insert to expedite the processing of your approved Workers Compensation prescriptions, based on the established parameters by Chartis Insurance . Dear Pharmacist, Please call the TmesysTM Pharmacy Help Desk, 1-800-964-2531, to establish First Fill eligibility and obtain the ID# necessary for the online processing of Workers Compensation medication for this newly injured worker. Your company has signed an agreement to participate in the TmesysTM Workers Compensation PPO. Please contact the TmesysTM Pharmacy Help Desk and inform the TmesysTM Help Desk Representative that there is a newly injured worker at your pharmacy filling an Chartis Insurance First Fill prescription. Sincerely, Tmesys(, Inc. ALL PARTICIPATING PHARMACIES HAVE NOT BEEN INCLUDED ON THIS LIST. PLEASE CALL TMESYS REGARDING ANY QUESTIONS (800) 964-2531CHAIN NAMEINDEX NAMECHAIN NAMEINDEX NAMECHAIN NAMEINDEX NAMECHAIN NAMEINDEX NAMEA & Pindex: TYSHappy Harry'sindex:TMEPic & Saveplan name: T or TMESYSTurner DrugsIndex: TmesysArbor DrugCarrier code: TIHarco Phcyindex: TYSPrevo Drugsinput code: TSTwin Valuecarrier code:TYSBartell DrugIndex: TMSHi-School PharmacyTMESYS Central Billing code:TM01Publixcarrier:TME plan: SYS or TYSU-Saveindex: TMEBig Bindex: TYSHEB Phcyprice code:T9Raley's/Bel Air Phcyplan: TmesysUnitedTYSBiggsCarrier code: TYSHooks, Brooks& Super X(HIS)index: TME Randalls PharmacyTMSRXVonscarrier: TMEBi-Lo Pharmacyinput code: TMSHorizon PharmacyTYSRevco drugsTMWCVIX Pharmcaycarrier code: TMEBi-Martindex: TMESYSHyVee Drugtownindex:bin # in 3rd party set upRite-Aid drugsTMESYSWalgreenscarrier code: TMEWCBrooks DrugsCode: TMEJ & J PharmacyTCSRX Discount Pharmacyinput code:TMEWal-Mart phcycarrier: TMEBrookshire BrothersCondor Code: 2050Joel & Jerry'sindex: TMESack-n-Saveplan#: 6012 or 5097Wegman Pharmacycarrier code: TME Cardinal Healthindex: Call supportK & BPlan code:TMESYSSafeway Phcyprocessor code: TME or TYSWeis Marketscarrier code: TYSCub PharmacyCarrier Code: TYSKash N Karryplan: TYSSav-A-Lot60Winn-Dixieindex: TME (plan 2066)CVS DrugsCondor Code: 8822Kerr DrugsTMESYSSams Club Pharmacycarrier code: TME*ALL PARTICIPATING PHARMACIES HAVE NOT BEEN INCLUDED ON THIS LIST. PLEASE HAVE YOUR PHARMACY CALL TMESYS REGARDING ANY QUESTIONS/AUTHORIZATIONS (800) 964-2531.Drug EmporiumTYSK-mart phcyCarrier code: TYSSave MartCarrier code: TYSDrug Fairindex: TMESYSKroger Phcyindex: TS,TM,YSShopko PharmacyTYSDuane ReadeTMESYSLaverdiere'splan name: TMESYSShop N Savecarrier code: TYSEckerds(FL)Termimal plan:2802(FL)Lifecheck DrugTMESYSShop-RiteTYSEckerds(all others)Termimal plan:2801Long's Phcyplan: #1,TMESStop N Shop146Franck's Pharmacyprice code: TMMedicine Shoppevaries by each store systemSuper DPlan name:332Fred MeyerTYSMedistat PhcyCondor code: 2425Super Valucarrier code: TYSFred's PharmacyTMESYSMilner-Rushing Drugscompensation as Tom AshleySuper X (HSI)index: TMEGenoveseNow Eckerd Drugs!National Supermarketsuse "Separate Plan Number"Thrift Drugcarrier code: 4139Giant Eagle Pharmacyindex:TME (Do not use WC plan code)NOB Hill Phcyplan: TMESYSThriftway Pharmacy2066Giant PharmacyTMESYSPathmark PharmacyTYSTom Thumb Phcypdx code: TMSGoodingsTME index D, bill code TMEPerry Drg Strindex:TSTops Pharmacyaccess code: TIHannaford Food & Drugindex: TYSPhar-MorTYSTri Daly DrugsCarrier code: TMS INFORMATION SHEET TAKE TO PHARMACY Claimant Name:________________________________Social Security #:__________________Date Of Injury:____________Employer________________________________________ Dear Patient, On your first visit, please give this notice to any pharmacy listed on the back of this insert. Dear Pharmacist, Your company has signed an Agreement to participate in the Tmesys( Workers Compensation Pharmacy PPO. You may or may not have personally seen the information plan sheets that were sent out by your headquarters. Although different pharmacies index our program under different names, most companies use some derivation of our name for the plan name. On the back of this form, you will find several examples of indexes used by various chains. If you do not find us in your computer or your plan book, please call Tmesys( immediately at 800-964-2531. Thank you for your help. Sincerely, Tmesys(, Inc. DTU    9 ; d f ƿʹtititi\iO\i\hTs56CJOJQJh56CJOJQJh6CJOJQJh6CJH*OJQJhCJOJQJh56CJH*OJQJh5CJOJQJjhCJUmHnHuh5CJOJQJ h5CJ hTs5CJ hCJh56CJOJQJh h6CJh6>*CJ hCJ h4'(CJU   ~~~$If[kd$$If8Z,(,04 ax$Ifdd($xa$x    D E 12WX;<BCøqaqaqaqaqaqaqaqaqaqaqaqhB*CJOJQJhphhB*CJ OJQJhph!h5B*CJOJQJhph!h5B*CJ OJQJhph!h6B*CJOJQJhphhh5CJOJQJh5CJOJQJ jh56CJOJQJh56CJOJQJh5CJOJQJhCJOJQJ# $If $Ifkd$$IfִZ ."&,TF0    4 ax   ) 6 D $IfD E P $Ifkd$$IfִZ ."&,TF0    4 axP a l w $If $Ifkd$$IfִZ ."&,TF0    4 ax &1$If128 $Ifkd$$IfִZ ."&,TF0    4 ax8CLZo|$If $Ifkd<$$IfִZ ."&,TF0    4 ax$If $Ifkdf$$IfִZ ."&,TF0    4 ax#'38EW$IfWX` $Ifkd$$IfִZ ."&,TF0    4 ax`n}$If $Ifkd$$IfִZ ."&,TF0    4 ax .;$If;<P $Ifkd $$IfִZ ."&,TF0    4 axPbq|$If $Ifkd $$IfִZ ."&,TF0    4 ax#0B$IfBCP $Ifkd8 $$IfִZ ."&,TF0    4 axPboy$If $Ifkdb $$IfִZ ."&,TF0    4 ax $$Ifa$$IfFH46IK$&oq2u{=JKqz޽޽޽޽޽޽޽ޭޭޭޭޭxmxhTs6CJOJQJh{&CJOJQJh{&6CJOJQJ h{&5CJ h{&6CJ h{&CJ h{&CJ hCJhB*CJOJQJhph!h5B*CJOJQJhphhB*CJOJQJhphhB*CJ OJQJhph!h5B*CJOJQJhph)0***$Ifkd$$If4֞Z .",TF 04 axf4 $$Ifa$$If"0***$Ifkd$$If4֞Z .",TF 04 axf4"2BFG $$Ifa$$IfGHT[h0***$Ifkd$$If4֞Z .",TF 04 axf4hz $$Ifa$$If0***$Ifkd$$If4֞Z .",TF  04 axf4 $$Ifa$$If 0***$Ifkd$$If4֞Z .",TF  04 axf4$045 $$Ifa$$If56HWg0***$Ifkd'$$If4֞Z .",TF  04 axf4g $$Ifa$$If0***$IfkdF$$If4֞Z .",TF  04 axf4 $$Ifa$$If0***$Ifkde$$If4֞Z .",TF  04 axf40>IJ $$Ifa$$IfJKTf|0***$Ifkd$$If4֞Z .",TF  04 axf4| $$Ifa$$If0***$Ifkd$$If4֞Z .",TF  04 axf4 $% $$Ifa$$If%&5<N0***$Ifkd$$If4֞Z .",TF  04 axf4NRaop $$Ifa$$Ifpqz0***$Ifkd$$If4֞Z .",TF  04 axf4 $$Ifa$$If0***$Ifkd$$If4֞Z .",TF  04 axf4  $$Ifa$$If 0)))$a$kd$$If4֞Z .",TF  04 axf4 !"#$%&'()*+,-./0123456789:;$&dPa$$a$;<=>?@ABCDEFGHIJKLMNOPQRSTUVW$a$WXYZ[\]^_`abcdefghijklmnopqrs$a$stuvwxyz{=Kxgd{&xgd{&$a$gd{&gd{&$a$ hCJh{&6CJOJQJ jh{&6CJOJQJh{&5CJOJQJh{&CJOJQJ jh{&CJOJQJ (/ =!h"h#h$.% njiH:?iPNG  IHDR|i1PLTE@@@@@@@|RP|iE`$V]M:Y||^ $]V@GVԁ`P]V&oԁVGH߄GFP_߄gl_GLv_d݅o`ogl_`$:Yef_n$*of*YYYfo| Y̔loz gtg1R-+W21J?'m'x) sySmeVh hYxWWofoVBV_Fo߆EF߆_GJg8V@ X\ f.d:&?OMHDf/RhP߇Eh߇(Ghj_GJ_dEhjRgVT Y] dd:&oOMH.ڋd/>,:~ĐbKGDH cmPPJCmp0712HsIDATx^˖$)D{=ϝ w2ZLBHY?Aoм1md_ @7,1q @7,1q7 4dʀg%Οk\_3=l{8fyޫ7r_ô[`h0_[Bw ֑.>7Cϱy|or翀 .-~|[JZ|U!3kU.|2$o >%|[O?|,|Л1oKo/Iwހ/z3y>>ͬ}{վ MI 7xJ_o2s|w&$oV .Jޜ7ހMI_q97z36+ӳ7{K8?{e oP{I[P>MǷ.gKO+zThQ90*Wԋ´"C [c갳6ARׂ46W‡WU8VFzI+o:lSO.iKPhn[L2bZdÙ3{0||RGD|s>$ E^_f 1.c~l_{dfx|ڥʓ~UArujq>Y,_J ł> 6|3Wz>'HIl0kt++_ Vx,|sWzx7>$8*gq`͌^Sp+wGN s ᛟ'nLoj:@o޹` ܍Z-"{t|n6 B!czjDdRʦjrX,߂Y@$K\ kPr?&+w+GW?cO÷0z{KOt oaq;GT<-{˸;@Y{ z㤉I{{wMitF^Doێ&'e|M9]R.`%tܨoו ߸qm|d/ȞĀJ_` '^g>C,40c8KgffE]$l&Q7\XH0SrPz߻ rss^(]lj+i8|!{C_^Lg _w.wM-|ޅӆH=vT_^1cۍ7g3e3{|]%]faCLuL)svb_2zm1[/dQ ID_-nY]o5Q`PisvΛʶ| ]P@O+ =o{56B,6{Vq/7sF+ߖԙS%|]&o5X=).C3x#/ÑH+>ޥx\]PmI>%=(騶18)|/cKu).(_T>΅G7j, }frQ=䑏vp@=N< _S9Ky I{ 4iLqoL϶W ]`OY|J?/SY=%{W>#wz)_.]Ԏ _'nfu܍|6>[Yz`;|5܍mvߺn+c}i`n GW :_F7munm/m֙- j}=zs7!|^u`/2L`O@+=)7fO-̖d<{|D쵁/ؓ-s8{,wbŸGY g|{>sH^zM?+>>`#iҗzy_"U/a>3w|]zϣ.ddE- Y]:2O`/ ^-M e[>ree+{1rY|z"0ܑ#]=+=W[6/d,Sg1[|N)䌳—J@7#}b6)䌳çb#~eF^LcOB7ϴ^K93/o)^LS ӣirV ޿o)^L31B"`2PUzC3\f]E۴AaeJ ..j_6O{6Ҟb >5.dMT9{G,Ri2gIHu]VKGm&5~=Lk8Md"Kە(0T~%3!OY`yR'#k⨆ݖH6$Mr$-4]gzݭ?8kƤ&b]X\!SL=7;|HNY9g, ^>UF۲iw~J|{ٔAsF>O/$M$jt |"%q   >=ɣBł3'$ܣ 4k-TfUxPWy_@{LOzX?|'S(ڄ2  e_} S/-09HtQτ!D[qhvT2}<|/QW4p n)Qa| BrSn= |7N H_kUrj٠۪R.lR<_WT,}W+<jz%[]k>#<J|;#!iQ1MiJFe* '>n's?"E Ua&v𱺇UƍBυ/ wUIqN1Ow 5INet ,<S. B(bB涫>PIN, n]>Iunha {gФlؙc/3a 2}.CT>_aGCbs?QQ# >%13&̧cU~>s=(D_0I@AC8|b)/ R/o")^1=8T:.)}TXEb6H=o]كHIgE{~*Ÿ7El {E^(߹[^z?Re#|ѐ0 {|J€Hs=75|@szk*}51_B>%,>'("cngPЮ n{)V@T+;?|U'6 \u2+L>yD=#IӬ b,|&L)# i%{_ R2P >\D HP\m0#_Cm'Hfu'>d 4~55gc_R1Hƥ_4Q-{vgDX'WtC.LȈH @j%?ů h={|)"Ֆ>Rc MJ*ꩥ)nw[4x rJ_\յ9!|cI>`( o@`b"|BH;/N|K">OP/&ܖhO!|emxj'MY§,^_E?+RsNq:\8er@߾ay/* V>gMob.C-RPzCʑ`gd=mPWC/||֦:.9>9*g񦦐lKIf< h),|'U1"tM:8 H|r~!1$;>C7ӎ/!wi2} )a"߭]},{ ᓖGmv(W?:G\ZrJq(sq7#|wuot|Xny݀SE\"mp䫎q?^P`/K?eF*@]/W&}l ̫~![<Tqo{]R,Ali0/7>"{EcPNGOԂHÀhX F{B+CװJ(gT)@('/2y-QC<_VT`QKG>X.+ 7>#.fHNS{cbvOn)JxBx|=SK|9π{):Ȧ3>1儏7cjQ>4^CZ9Z:L1ݚJ]d<RY)bdB >5^\ee35_'<] >6@Bç\X>L .i>q#;0۷0 5 ,s 1uc-ߞ瀏ګI<*_Is=q-r HCZ$dCLu%:@ fU%N@Ti'L+No&۞<XG[5(52;2+Q`׼L DH?*~&# {o?`[twrY=Is)Coī/UU:ul&ʧngoC#|ٽ]T49z/}3lovĀTs -Ѓk/|@LRu/С.ͦsnCuU,4㢅3k"Mz6>w-}؄n-|}mcK:k2eϽ&q|D@ubwj*r_|-铳.;ۮ.xko_3nX.ĝcm{?>;J׾E9$UDEvgtZzz]Z)DY(mlI{OZ͢U4"|oV*ᛑӶ~5}byjji f;ˋKRm7Hvs\B<>oU\Ɠ1 .wn\ӗyH&c#җ5%Umg-H)YEBzR>g!sݜr,sr,|H8&pc Eμ`s9|#4뵨ʉ7oP-v6wU~ 8Zi_GC[WZ;5壩s/ kPp쁦%Zycڼ=3|R؅/Nbg>Y@gtj _ߞT&$Ʒܿ>Uΐ5!~v(_u ʷ}$>XI?QzXl $%}=֓~ZHQ53T>_XUJD+g |>o7(*XO||苲%A[}q Wey[mik3 )_o^X8|-G~2))l;2 Grٌ d 3Ic8d d-Ƙd 3Ic8d d-Ƙd 3Ic8d d-Ƙd 3Ic8d2V.IENDB`$$Ifx!vh5(,#v(,:V 80,5(,44 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax($$Ifx!vh5555T5F555#v#v#v#vT#vF#v#v#v:V 0,5555T5F55544 ax$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf4$$Ifx!vh5555T5F55 #v#v#v#vT#vF#v#v :V 40+,5555T5F55 44 axf48@8 Normal_HmH sH tH Z@Z Heading 1$$@&a$56B*CJOJQJhtH uDAD Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List BB@B Body Textx6CJOJQJ@>@@ Title $a$5CJOJQJU)6DEPalw&128CLZo|#'38EWX`n} .;<Pbq| # 0 B C P b o y   " 2 B F G H T [ h z  $ 0 4 5 6 H W g  0 > I J K T f | $%&5<NRaopqz  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{=Kx0000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 +K D P 18W`;PBP"Gh5gJ|%Np ;Ws !"#$%&'()*,-./0123456789:;<=>?@ABCDEFGHIJl  ,b$jiH:?i*@ (  n  C 0ATmesys Logo"B S  ?&R,vTd3;^f =Cafgkw| GKZejnu{<Dnst|})-  b f i n y |  ! [ g   \`adqyhj333XX`tqz^Ts4'({&Z\)6DEPalw&128CLZo|#'38EWX`n} .;<Pbq| # 0 B C P b o y   " 2 B F G H T [ h z  $ 0 4 5 6 H W g  0 > I J K T f | $%&5<NRaopqz @XXbXXP@UnknownGz Times New Roman5Symbol3& z ArialA& Arial Narrow"qh+ & &> "> "i24d2QHP(?\2\C:\Documents and Settings\mxm5506\Application Data\Microsoft\Templates\FIRST FILL EFORM2.dot9Carrier/Insured Prescription Processing Information SheetMXM5506JRopersOh+'0 8 HT t   <Carrier/Insured Prescription Processing Information SheetMXM5506FIRST FILL EFORM2.dotJRopers3Microsoft Office Word@Ik@l@k@l>՜.+,0  hp|  PCA" ' :Carrier/Insured Prescription Processing Information Sheet Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ\]^_`abcdefghijlmnopqrstuvwxyz{|}~Root Entry F X݇Data [>1TablekAWordDocument9SummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q