Awprx Temporary Prescription Form - Calhoun City Schools


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AWPRx Temporary Prescription Form
1)Instructions for the MUNICIPALITY:
Provide this form to your injured worker to have any prescription filled for a temporary 7 day
supply and please fill out the information below:
Claimant Name: _________________________________SSN: _________________________
Claimant DOB: _____________ Claimant Home Phone #: ____________________________
Claimant Employer: __________________________________ Date of Injury: ___________
Claimant Address: _____________________________________________________________
City: _____________________________ State: ______________ Zip: _________________
Employer Representative: ____________________________________ Date: _____________
2)Instructions for the INJURED WORKER:
You, the injured worker will need to bring this form and provide it to the pharmacy. The pharmacy
will need to call AWPRx to activate you within the system. Once active, it will take a few minutes to
process your medication(s). ***Please contact AWPRx customer service at 1-888-700-0922 if a
prior authorization is required to fill your medication.
3)Instructions for the PHARMACY:
Call AWPRx at 1-888-700-0922, so the injured workers eligibility can be turned on. After obtaining
the injured workers information, AWPRx will provide the online processing information.
Prescription(s) will fill for a 7 Days Supply Here. If there is a remaining balance on the script after
the 7 Days Supply Here is filled, AWPRx will call back the following business day and let you know
if the balance has been approved.
***AWPRx office hours are Monday through Friday, 8:00AM EST to 8:00PM EST. We also have
representatives on call 24 hours/7 days a week. If you need to get a temporary fill outside of normal business
hours, please dial the 1-888-700-0922 number, and leave a message for our on-call team. Please state in your
message that you have a member with a temporary prescription form that needs to be set up, and please
also leave your pharmacy name and phone number.


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Parent category: Medical