Michigan Counties Workers' Compensation Fund

First Prescription Fill Form

CompOne Administrators, Inc.

Workers’ Compensation Prescription Information

Use the form below to submit your request. Alternatively, you may download, print and mail a completed copy of the First Prescription Fill Form (PDF) to:

CompOne Administrators
PO Box 2530
Okemos, MI 48805

If you need a paper copy of your submission, please print the PDF and fill out with your information. If you choose to submit via the online form, your information is secure and sent directly to the CompOne team, but you will not receive a paper copy of your submission.

EMPLOYER

Please fill out employee information below and provide employee with this document to take to any pharmacy with prescriptions.

Employee Name(Required)

First Last

Group Number: 10602788

Member ID(Required)

Date of Injury(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Processor: myMatrixx
Bin Number: 014211

Day supply is limited to 30 days for a new injury.
myMatrixx Help Desk: (877) 804-4900

EMPLOYEE

CompOne Administrators, Inc. has partnered with myMatrixx to make filling workers' compensation prescriptions easy.

This document serves as a temporary prescription card. A permanent prescription card specific to your injury will be forwarded directly to you within the next 3 to 5 business days.

Please take this letter and your prescription(s) to a pharmacy near you. myMatrixx has a network of over 64,000 pharmacies nationwide. If you need assistance locating a network pharmacy near you, please call myMatrixx toll free at (877) 804-4900.

IF YOU ARE DENIED MEDICATION(S) AT THE PHARMACY, PLEASE CALL (877) 804-4900.

PHARMACIST

Please obtain above information from the injured employee if not already filled in by employer to process prescriptions for the workers' compensation injury only.

For questions or rejections please call (877) 804-4900. Please do not send patient home or have patient pay for medication(s) before calling myMatrixx for assistance.

NOTE: Certain medications are pre-approved for this patient; these medications will process without an authorization. All others will require prior approval.

FOR ALL REJECTIONS OR QUESTIONS CALL: (877) 804-4900.