Please read this notice carefully. It provides you with important information on getting medication under a workers' compensation claim.
As of [date], [Name of carrier] has entered into an agreement with [certain pharmacies/a pharmacy benefit manager] to make available the medications workers may receive for their work-related injury or sickness. This does not change your right to get the medication necessary to treat such an illness or injury. It only means that you must obtain that medication from [these pharmacies or pharmacy chains/the pharmacies or pharmacy chains identified by the pharmacy benefit manager]. [These pharmacies/this pharmacy benefit manager] are set forth on the [attached sheet or benefit card]. This [sheet or benefit card] contains important information concerning your pharmacy benefits. Bring it with you to the pharmacy when dropping- off or picking-up a prescription, or if you obtain your prescriptions by phone, mail or internet, have the [sheet or card] available when requesting the prescription.
If you are obtaining your medication through a workers' compensation claim, you need to obtain that medication from one of these pharmacies unless:
Please note that certain pharmacies/pharmacy benefit manager may require you to use the Internet, mail-order or telephone pharmacies. An order can be placed with them by [Describe procedures for such order.]
All pharmacies are required to keep a sufficient stock of medication on hand so that they can service you without undue delay.
All in-store pharmacies must be open for business during hours that are typical in your community.
These pharmacies will directly bill [carrier] so you will not have to pay out of pocket.
You may obtain additional information about [these pharmacies] from the following website: [list website], or toll free 24 hour telephone number: [list number].
If you have any questions or problems, please call [Name and Number for carrier information]. You may also contact the New York State Workers' Compensation Board at firstname.lastname@example.org or by phone at 1-877-632-4996 or the Advocate for Injured Workers at 800-580-6665. You may also find further information on the web at www.wcb.ny.gov.
Please Note: The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's web site.