If your workers’ compensation doctor gave you a prescription, you must visit one of the First Script Pharmacies and take this form with you when you fill your prescription.
SECTION 1 – Pharmacy
The Commonwealth of Virginia participates in First Script, a pharmacy benefit program administered by MEDCO. Please call the First Script Help Desk, 24 hours a day, 7 days a week, at 1-800-791-2080 to verify employee eligibility. First Script claims are submitted electronically and electronic approval of the claim will be returned. You will not be required to submit any paperwork for this claim and payment is guaranteed for approved claims.
On-Line Claim Information:	Claims are processed through the MEDCO network.
Group #:	FSNCVTY
BIN #:	610014
PCN #:	NOT APPLICABLE
Member ID #:
First Script will provide Member ID # upon verification of eligibility
SECTION 2 – Employee
First Script is valid only for medications prescribed for your work-related injury. You or your group health insurer are financially responsible for any other prescriptions. First Script is available at nearly 56,000 pharmacies nationwide. To locate a nearby pharmacy, please call First Script Customer Service at 1-800-791-2080. Some participating First Script pharmacies may be:
Costco	Food City	Kmart	Sam’s Pharmacy	Walgreens
CVS	Food Lion	Kroger	Shoppers Pharmacy	Wal-Mart
Eckerd Drug	Giant	Medicine Shoppe	Target	Winn-Dixie
Farm Fresh	Harris Teeter	Rite Aid	Ukrops
PHARMACY BENEFIT PROGRAM Commonwealth of Virginia Employer Information Card	Please complete the information below before giving this form to your pharmacist.
DEPARTMENT OF FORESTRY	Employee Name:
Agency Name	Social Security #:
Agency Code:	CV411000	Sub-Agency:	N/A
Questions? Call First Script Customer Service at 1-800-791-2080