WORKERS’ COMPENSATION Rx PROGRAM
Letter of Intent for First Choice Rx Prescription
The top portion of this form must be completed before giving it to your pharmacist.
Injured Employee: _______________________________ Social Security #____________________
Date of Injury: ___________________ Employee Phone: __________________________________
Employee Date of Birth: _____________ Description of Injury: ____________________________
Employer Name: ________________________________________________
Employer Representative: ________________________ Phone: ____________________________
To Employer:
Please complete and give this form to the Injured Employee. The Employee may take this completed form to any
pharmacy to expedite the processing of their approved workers’ compensation prescriptions. For your
convenience, some of the major pharmacy chains are listed below.
To Pharmacist:
This employer has selected MSC–Medical Services Company to administer its workers’ compensation prescription
drug program through the RESTAT network. For immediate authorization and online billing information,
contact MSC at: 1 800 848 1989 ext 1414. Please state that you have received a Letter of Intent and give the MSC
patient care coordinator the MSC control number located in the bottom right hand corner of this form.
CHAINS PARTICIPATING IN THE PHARMACY NETWORK
A & P PHARMACY
FAGAN PHARMACY
KERR DRUG STORE
SAVE MART PHARMACY
ALBERTSONS
FARMER JACK PHCY.
KING SOOPERS
SCHNUCK’S PHARMACY
ARBOR DRUGS
FAY’S DRUG STORE
KINNEY DRUGS
SHOP ‘N SAVE DRUGS
ARROW PRESC. CTR.
FINAST PHARMACY
KROGER DRUG
SHOPKO PHARMACY
AURORA
FOOD TOWN PHCY.
LONG’S DRUG STORE
SMITH’S FOOD & DRUG
BARTELL DRUG
FRED MEYER
MANAGED PHCY. CARE
SNYDER
BI LO PHARMACY
FRED’S PHARMACY
MARC’S PHARMACY
STOP & SHOP PHCY.
BI MART DRUG
FRY’S FOOD & DRUG
MAXI/BROOKS PHCY.
SUPER D DRUGS
BIG BEAR
FURR’S PHARMACY
MEDICAP PHARMACY
TARGET PHARMACY
BROOKS PHARMACY
GENOVESE DRUG STORE
MEDIC DISC. DRUG
TEXAS DRUG WRHS.
BROOKSHIRE
GIANT EAGLE PHCY.
MEDICINE SHOPPE
TEXAS ONCOLOGY
BRUNO’S
GIANT FOOD INC.
MEDISTAT PHARMACY
THRIFT DRUG
CARRS
GIANT PHARMACY
MEIJER PHARMACY
THRIFTY/PAYLESS DRUG
CITY MARKET
GRAND UNION PHCY.
OSCO DRUG
THRIFTY WHITE DRUG
COSTCO
HANNAFORD DRUG
PAMIDA PHARMACY
TIMES PHARMACY
CUB PHARMACY
HARCO DRUG
PATHMARK PHARMACY
TOM THUMB/PAGE DRUG
CVS PHARMACY
HARVEST FOODS PHCY.
PERRY DRUG STORE
TOPS PHARMACY
D & W PHARMACY
H E B PHARMACY
PRICE CHOPPER
UNITED MANAGED CARE
DILLON PHARMACY
HI SCHOOL PHARMACY
PRICE COSTCO PHCY.
UNITED PHARMACY
DISCOUNT DRUG MART
HORIZON
PUBLIX PHARMACY
VON’S PHARMACY
DOMINICK’S
HY VEE PHARMACY
RANDALL’S FOOD MKTS.
WAL MART PHARMACY
DRUG EMPORIUM
INTEGRATED PHARMACY
RITE AID PHARMACY
WALGREENS
DRUG FAIR
K & B PHARMACY
RITZMAN PHARMACY
WEIS PHARMACY
DUANE READE
K MART
SACK N’ SAVE
WELBY SUPER DRUG
EDGEHILL PHARMACY
KARE DRUGS
SAFEWAY PHARMACY
WINN DIXIE PHARMACY
EDWARDS PHARMACY
KASH & KARRY PHCY.
SAV ON DRUGS
MSC Control Number:
00710