TEMPORARY FIRST FILL PRESCRIPTION LETTER FOR NEW WORK RELATED

Temporary First Fill Prescription Letter for New Work Related Injuries

Dear Injured employee:

Using this letter makes it easier to obtain medications prescribed by your doctor for the treatment of your workers’ compensation injury. This letter can only be used (1) one time and will allow up to a (14) fourteen day supply of medications.

On your first visit, please give this notice to the pharmacist to expedite the processing of your Worker’s Compensation prescriptions. With the CorVel pharmacy program, you do not need to complete any paperwork or claim forms. Simply present this CorVel First Fill Prescription Form to the pharmacy. You should not incur any costs or co-payments at the pharmacy. You may receive a CorVel Pharmacy card in the mail once your claim has been reported to and evaluated by Corvel’s Claim Specialist.

Please note that this card can only be used for prescription medications related to your workers’ compensation injury. It cannot be used for obtaining medications unrelated to your claim.

NOTE TO PHARMACIST:

Please use the BIN, PCN, and RxGroup number below to process an online/electronic claim to CorVel:

B

Disclaimer: Receipt of this correspondence does not constitute the acceptance of your claim. Your employer and/or insurer reserves all rights under state regulations to properly investigate and make determinations of liability regarding your claim.

IN: 004336

PCN: ADV

Group Number: RXFFWC300

To Generate Member ID: The Injured Worker’s 9 digit Social Security Number plus 8 digit Date of Injury will be used as their 17 digit Member Identification number when processing their First Fill Prescription: XXXXXXXXXMMDDYYYY

***Please contact CorVel Pharmacy Department at (800) 563-8438 for assistance with claims processing***

There are over 65,000 Participating Pharmacies in the CorVel Network. Below is a sample listing. Call (800)563-8438 for a participating pharmacy near you.

CostCo Pharmacy	H.E.B. Pharmacies	Meijer Pharmacy	Smith’s Food & Drug Centers
CVS	Hy-Vee Pharmacy	Publix Pharmacy	Target Pharmacy
Dominick’s Finer Foods	Ingles Pharmacy	Raley’s Drug Center	Von’s Pharmacy
Drug Mart	Kroger Pharmacy	Rite Aid Pharmacy	Wal-Mart Pharmacy
Fred’s Pharmacy	Longs Drug Store	Safeway Pharmacy	Walgreens Pharmacy
Giant Eagle Pharmacy	Marc’s Pharmacy	Sav-On Drug Store	Wegman Pharmacy
Giant Food Stores, LLC	Medicine Shoppe	Shoprite Supermarkets	Winn Dixie Pharmacy

Sincerely,

CorCareRx Team

CorVel Corporation

Managing Agent for the NC Office of State Personnel