Workers Compensation Fund toll-free: 800.446.COMP web: www.wcfgroup.com WORKERS COMPENSATION FUND Rx PROGRAM Workers Compensation Fund has partnered with organizations throughout Utah to provide discount prescription drug prices for injured workers. To properly utilize this form, employers should fill out the top portion and give to the injured worker to take to one of the pharmacies listed at the bottom of the form. An electronic version of this form is available on our website at wcfgroup.com under WCF Online. THE FORM BELOW MUST BE COMPLETED BEFORE GIVING IT TO YOUR PHARMACIST. Injured Employee: ___________________________________ Social Security #: _______________________ Employee Date of Birth: ____________ Employee Phone: ________________ Date of injury: ______________ Description of Injury: _______________________________________________________ Employer Name: ________________________ Employer Contact: ________________ Employer Phone: ________________ Policy Number: ______________ ___________ __________ _ To Employee: On your first visit, please give this notice to any pharmacy listed on this panel to expedite the processing of your workers’ compensation prescriptions. (Based on the established parameters by your employer.) For a more comprehensive list of local participating pharmacies, please call MSC at 1-800-848-1989 x 1414. To Pharmacist: This employer has selected MSC – Medical Services Company to administer it’s workers’ compensation prescription drug program through the RESTAT network. For immediate authorization and on-line billing information contact MSC at: 1-800-848-1989 ext 1414, state that you have received a letter of intent and give the MSC patient care coordinator the control number located below. tate below Control Number: 05338 CHAINS PARTICIPATING IN THE PHARMACY NETWORK ALBERTSONS JOLLEY CORNER PHARMACY SAM’S CLUB ALTA VIEW HOSPITAL PHARMACY JORDAN VALLEY PHARMACY SAV-ON DRUGS AMERICAN FORK HOSPITAL PHARMACY K-MART SHOPKO PHARMACY CITY MARKET KROGER DRUG SMITH’S FOOD & DRUG COMMUNITY PHARMACY INC LDS HOSPITAL PHARMACY STOP & SHOP PHARMACY COSTCO LINS PHARMACY TARGET PHARMACY COTTONWOOD HOSPITAL LONG’S DRUG STORE THE ORTHOPEDIC SPECIALTY HOSPITAL CVS PHARMACY MACEY’S PHARMACY THRIFTY/PAYLESS DRUG DAN’S PHARMACY MCKAY DEE HOSPITAL PHARMACY UNITED MANAGED CARE DAVIS HOSPITAL & MEDICAL CENTER MEDICINE SHOPPE UNIVERSITY OF UTAH HOSPITAL PHARMACY DIXIE MEDICAL CENTER & PHARMACY MOUNTAIN VIEW HOSPITAL PHARMACY FOOD TOWN PHARMACY OSCO DRUG UTAH VALLEY REGIONAL MEDICAL CENTER PHARMACY FRED MEYER PIONEER VALLEY PHARMACY VALLEY VIEW MEDICAL CENTER PHARMACY FRY’S FOOD & DRUG VON’S PHARMACY HARMON’S PHARMACY PRIMARY CHILDRENS MEDICAL CENTER PHARMACY SALT LAKE REGIONAL PHARMACY REAMS PHARMACY WAL-MART PHARMACY HUNTSMAN CANCER PHARMACY RITE-AID PHARMACY WINEGAR’S PHARMACY IHC HEALTH CENTER SAFEWAY PHARMACY WINN DIXIE PHARMACY WALGREENS American LegalNet, Inc. www.FormsWorkflow.com