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Instructions for employers at time of injury

Introduction
Tokio Marine has chosen the Tmesys Pharmacy Program to facilitate newly injured
employees’ prescriptions with no out-of-pocket expense at nearly 60,000 pharmacies
within the Tmesys network. To encourage injured employees to fill their prescriptions
at participating pharmacies, Tmesys developed a First Fill program.

Benefits of a First Fill program• Savings are captured on initial prescriptions• Eligible employees are automatically transitioned to Retail Drug Card once claimis established• No out-of-pocket expenses for injured employee when First Fill card is utilized

Instructions at time of injury
At the time of injury, follow the instructions below to ensure the injured employee
obtains prescriptions through the Tmesys First Fill program:

Step 1 Provide the claimant with a First Fill form at the time of injury. The card
portion of this document must be completed with claimant’s name and date ofinjury.

Step 2 Instruct the claimant to present the First Fill card to the pharmacy toobtain the prescription(s). Most pharmacies and all major chains are included in
the Tmesys network. To find a network pharmacy, instruct the claimant to call
1-866-599-5426 or visit tmesys.com.

Step 3 The employer will also complete the First Notice of Loss to Tokio Marine
This program offers unique solutions to provide appropriate prescription benefits tothe claimants while increasing the overall cost savings for the insured.
To learn more about this program, please contact (800) 628-2796 ext. 7742 or email
at: managedcare@TMAmerica.com.
To access the information online, please go to: www.tmamerica.com and click on
the Claims dropdown menu and select Cost Containment Solutions.

About Optum Worker’s Comp and Auto No-fault Solutions
Optum Workers’ Comp and Auto No-fault Solutions collaborates with clients to lower costs while improving healthoutcomes for the claimants we serve. Our comprehensive pharmacy, ancillary and managed care services, including
settlement solutions, combine data, analytics, and extensive clinical expertise with innovative technology to ensure
claimants receive safe, efficacious and cost-effective care throughout the lifecycle of a claim. For more information,email us at expectmore@optum.com.
Optum and its respective marks are trademarks of Optum, Inc. All other brand or product names are trademarks
or registered marks of their respective owners. Because we are continuously improving our products and services,
Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer.
© 2021 Optum, Inc. All Rights Reserved. Rev.01/21

To find a network pharmacy,
instruct the injured employee
to call 1-866-599-5426 or visit
tmesys.com.

PO Box 152539
Tampa, FL 33684-2539

MAKING IT EASY TO GET WORKERS’ COMPENSATION PRESCRIPTIONS FILLED
Optum has been chosen to manage your workers’ compensation pharmacy benefits for your employer or their insurer.
Below is your First Fill card that will allow you to receive your injury-related prescriptions at your local pharmacy. Please
fill out the card based on the instructions below.

Injured person:

Finding a network pharmacy

If you need a prescription filled for a work-related
injury or illness, go to an Optum Tmesys® network
pharmacy. Give this temporary card to the pharmacist.
The pharmacist will fill your prescription at no cost
to you.

Most pharmacies and all major chains areincluded in the network. To find a network
pharmacy call 1-866-599-5426 or visit tmesys.com.

If your workers’ compensation claim is accepted, youwill receive a permanent pharmacy card in the mail.
Please use that card for other work-related injury orillness prescriptions.

1-866-599-5426

Questions? Need Help?

Employer:
Immediately upon receiving notice of injury, fillin the information below and give this form tothe employee.

Attention Pharmacists: Call 1-800-964-2531 to establish First Fill benefit eligibility
and obtain the ID number for online adjudication of approved benefits for theinjured worker. Tmesys is the designated PBM for this patient.

WORKERS’ COMPENSATION PRESCRIPTION DRUG PROGRAM
Tokio Marine
CARRIER/TPA

EMPLOYER

Tmesys Pharmacy Help Desk
1-800-964-2531
NDC

INJURED PERSON NAME

Please provide directly to Pharmacist
SOCIAL SECURITY NUMBER

DATE OF INJURY (YYMMDD)

Envoy

RxBIN

004261or

002538RxPCN

CALorEnvoy Acct. #Notice to Cardholder: Present this card to the pharmacy to receive medication foryour work-related injury. To locate a pharmacy: tmesys.com.

NOTE: This First Fill card is only valid for your workers’ compensation injury or illness.

The following entities comprise the Optum Workers’ Compensation and Auto No Fault division: PMSI, LLC, dba Optum Workers’ Compensation
Services of Florida; Progressive Medical, LLC, dba Optum Workers’ Compensation Services of Ohio; Cypress Care, Inc. dba Optum Workers’
Compensation Services of Georgia; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; Settlement Solutions, LLC,dba Optum Settlement Solutions; Procura Management, Inc., dba Optum Managed Care Services; Modern Medical, dba Optum Workers’
Compensation Medical Services, collectively and individually referred as “Optum.”

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PO Box 152539
Tampa, FL 33684-2539

HACEMOS MÁS SENCILLO QUE SE LE ABASTEZCA LAS RECETAS DE SU PROGRAMA
DE COMPENSACIÓN POR ACCIDENTES LABORALES
Optum ha sido elegido para administrar los beneficios farmacéuticos de su programa de compensación por accidentes laboralespara su empleador o asegurador. Más adelante incluimos su tarjeta First Fill que le permitirá recibir las recetas médicas
relacionadas con su lesión en su farmacia local. Llene esta tarjeta siguiendo las instrucciones que se indican a continuación.

Persona lesionada:Cómo encontrar una farmacia de la red

Si necesita que se le abastezca su receta médica
para una lesión o enfermedad relacionada con
su trabajo, visite una farmacia de la red Optum
Tmesys®. Entregue esta tarjeta temporal al
farmacéutico. La farmacia abastecerá la receta
sin costo para usted.

La mayoría de farmacias y todas las grandescadenas de farmacias forman parte de la red.
Para ubicar una farmacia de la red, llame al
1-866-599-5426 o visite tmesys.com.

Si se acepta su reclamación del programa decompensación por accidentes laborales, recibirá
una tarjeta permanente por correo. Use esa
tarjeta para otras recetas médicas de lesiones oenfermedades relacionadas con su trabajo.

¿Tiene alguna pregunta?
¿Necesita ayuda?

1-866-599-5426

Empleador:
Inmediatamente después de recibir un aviso
sobre una lesión, llene la información queaparece a continuación y entregue este
formulario al empleado.
Attention Pharmacists: Call 1-800-964-2531 to establish First Fill benefit eligibility
and obtain the ID number for online adjudication of approved benefits for theinjured worker. Tmesys is the designated PBM for this patient.

WORKERS’ COMPENSATION PRESCRIPTION DRUG PROGRAM
Tokio Marine
PORTADORAEMPLEADOR

Tmesys Pharmacy Help Desk
1-800-964-2531
NDC

Envoy

NOMBRE DEL PERSONA LESIONADA

RxBIN

004261or002538

Please provide directly to Pharmacist

RxPCN

CALorEnvoy Acct. #NUMERO DE SEGURO SOCIALFECHA DE LA LESION (AAMMDD)

Aviso para el titular de la tarjeta: Presente esta tarjeta a la farmacia para recibir losmedicamentos para la lesión relacionada con su trabajo. Para ubicar una farmacia,visite tmesys.com.

NOTA: Esta tarjeta First Fill solo es válida para una lesión o enfermedad cubierta por su programa decompensación por accidentes laborales.

The following entities comprise the Optum Workers’ Compensation and Auto No Fault division: PMSI, LLC, dba Optum Workers’ Compensation
Services of Florida; Progressive Medical, LLC, dba Optum Workers’ Compensation Services of Ohio; Cypress Care, Inc. dba Optum Workers’
Compensation Services of Georgia; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; Settlement Solutions, LLC,
dba Optum Settlement Solutions; Procura Management, Inc., dba Optum Managed Care Services; Modern Medical, dba Optum Workers’
Compensation Medical Services, collectively and individually referred as “Optum.”

IMP14-2013-122