Please read this notice carefully. It provides you with important information on getting medication under a workers' compensation claim under a new law enacted in March 2007.

As of [date], [Name of carrier] has entered into an agreement with certain pharmacies 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. These pharmacies, and their addresses, are on the attached sheet.

If you are obtaining your medication through a workers' compensation claim, you need to obtain that medication from one of these pharmacies unless:

• You have a medical emergency and it is not reasonably possible to purchase the medications you need for that emergency.

• A mail-order, telephone or Internet pharmacy is not an option in the network, no pharmacy in the network will deliver to you, and none of these pharmacies is within ten miles if live in a rural area, or one mile if not. If you believe this is the case for you, please call one of the numbers on the bottom of this page.

Please note that [names of relevant pharmacies] are Internet, mail-order or telephone pharmacies. An order can be placed with them by [Describe procedures for mail order.]

All pharmacies on the attached list 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, and must post a sign saying that they serve injured workers who receive their benefits from [carrier].

These pharmacies will directly bill [carrier] so you will not have to pay out of pocket.

If you have any questions or problems, please call [Name and Number for carrier information] or Workers' Compensation Board at 1-877-632-4996 or the Board's Advocate for Injured Workers at 800-580-6665, or you can find further information on the web at www.wcb.state.ny.us.