First Fill SFM Clients

To the Pharmacist:

myMatrixx, an Express Scripts Company administers this workers’ compensation prescription program. Please follow the steps below to submit a claim. Standard first fill shall not exceed a 30-day supply or a cost of $750. This form is valid for up to 30 days from date of injury (DOI). Limitations may vary. For assistance, call myMatrixx, an Express Scripts Company Customer Care at 877.804.4900.

Pharmacy Processing Steps

Step 1: Enter BIN number: 003858

Step 2: Enter processor control: WC

Step 3: Enter the group number: F2SA

Step 4: Enter the injured worker’s nine-digit ID number

Step 5: Enter the injured worker’s first and last name

Step 6: Enter the injured worker’s date of injury