Carrier/Insured Prescription Processing Information Sheet



Chartis Insurance Injured Worker’s 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 Worker’s 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 Worker’s 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) 964-2531 |

|CHAIN NAME |INDEX NAME |CHAIN NAME |INDEX NAME |CHAIN NAME |INDEX NAME |CHAIN NAME |INDEX NAME |

|A & P |index: TYS |Happy Harry's |index:TME |Pic & Save |plan name: T or |Turner Drugs |Index: Tmesys |

| | | | | |TMESYS | | |

|Arbor Drug |Carrier code: TI |Harco Phcy |index: TYS |Prevo Drugs |input code: TS |Twin Value |carrier code:TYS |

|Bartell Drug |Index: TMS |Hi-School Pharmacy |TMESYS Central Billing |Publix |carrier:TME plan: |U-Save |index: TME |

| | | |code:TM01 | |SYS or TYS | | |

|Big B |index: TYS |HEB Phcy |price code:T9 |Raley's/Bel Air |plan: Tmesys |United |TYS |

| | | | |Phcy | | | |

|Biggs |Carrier code: TYS |Hooks, Brooks& Super|index: TME |Randalls Pharmacy |TMSRX |Vons |carrier: TME |

| | |X(HIS) | | | | | |

|Bi-Lo Pharmacy |input code: TMS |Horizon Pharmacy |TYS |Revco drugs |TMWC |VIX Pharmcay |carrier code: TME |

|Bi-Mart |index: TMESYS |HyVee Drugtown |index:bin # in 3rd |Rite-Aid drugs |TMESYS |Walgreens |carrier code: TMEWC |

| | | |party set up | | | | |

|Brooks Drugs |Code: TME |J & J Pharmacy |TCS |RX Discount |input code:TME |Wal-Mart phcy |carrier: TME |

| | | | |Pharmacy | | | |

|Brookshire |Condor Code: 2050 |Joel & Jerry's |index: TME |Sack-n-Save |plan#: 6012 or 5097 |Wegman |carrier code: TME |

|Brothers | | | | | |Pharmacy | |

|Cardinal Health |index: Call support |K & B |Plan code:TMESYS |Safeway Phcy |processor code: TME |Weis Markets |carrier code: TYS |

| | | | | |or TYS | | |

|Cub Pharmacy |Carrier Code: TYS |Kash N Karry |plan: TYS |Sav-A-Lot |60 |Winn-Dixie |index: TME (plan |

| | | | | | | |2066) |

|CVS Drugs |Condor Code: 8822 |Kerr Drugs |TMESYS |Sams Club Pharmacy |carrier 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 Emporium |TYS |K-mart phcy |Carrier code: TYS |Save Mart |Carrier code: TYS | |

|Drug Fair |index: TMESYS |Kroger Phcy |index: TS,TM,YS |Shopko Pharmacy |TYS | |

|Duane Reade |TMESYS |Laverdiere's |plan name: TMESYS |Shop N Save |carrier code: TYS | |

|Eckerds(FL) |Termimal plan:2802(FL) |Lifecheck Drug |TMESYS |Shop-Rite |TYS | |

|Eckerds(all |Termimal plan:2801 |Long's Phcy |plan: #1,TMES |Stop N Shop |146 | |

|others) | | | | | | |

|Franck's |price code: TM |Medicine Shoppe |varies by each store |Super D |Plan name:332 | |

|Pharmacy | | |system | | | |

|Fred Meyer |TYS |Medistat Phcy |Condor code: 2425 |Super Valu |carrier code: TYS | |

|Fred's Pharmacy |TMESYS |Milner-Rushing Drugs|compensation as Tom |Super X (HSI) |index: TME | |

| | | |Ashley | | | |

|Genovese |Now Eckerd Drugs! |National |use "Separate Plan |Thrift Drug |carrier code: 4139 | |

| | |Supermarkets |Number" | | | |

|Giant Eagle |index:TME (Do not use WC |NOB Hill Phcy |plan: TMESYS |Thriftway Pharmacy |2066 | |

|Pharmacy |plan code) | | | | | |

|Giant Pharmacy |TMESYS |Pathmark Pharmacy |TYS |Tom Thumb Phcy |pdx code: TMS | |

|Goodings |TME index D, bill code TME|Perry Drg Str |index:TS |Tops Pharmacy |access code: TI | |

|Hannaford Food &|index: TYS |Phar-Mor |TYS |Tri Daly Drugs |Carrier code: TMS | |

|Drug | | | | | | |

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.

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