Injured Worker First Fill Prescription Form (English & Spanish)

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GOALS OF THIS GUIDE

When utilizing the first-fill prescription program, an injured worker is provided necessary information to take with them to the pharmacy to fill prescriptions deemed necessary by their healthcare provider. Through the program, eligible prescriptions are filled at no cost to the injured worker within 15 days of the injury.  


For Employers:

Complete the employer section of the form below before providing to the Injured Worker.


For Injured Workers:

To fill your initial (first) prescriptions for a workers' compensation injury, present the form below within 15 days of the date you were injured. Then locate a participating pharmacy closest to you. More information is available in the form below.

Download First Fill Prescription Form in English

Download First Fill Prescription Form en Español

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Frequently asked questions

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How do I register as a policyholder?

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How do I register as a policyholder?

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How do I register as a policyholder?

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