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PHARMACY:  Commonwealth of Virginia participates in First Script, a pharmacy benefit program administered by ESI.  Please call the First Script Help Desk, 24 hours a day, 7 days a week, at 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.

Online Claim Information

Claims are processed through the ESI network
Group # FSNCVTY
BIN # 610014
PCN # Not Applicable
Member ID#
____________________________________________
First Script will provide Member ID# upon verification of eligibility

 

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 800.791.2080.

Please present this form to your pharmacist along with your work-related injury prescriptions.


 

Pharmacy Benefit Program

Commonwealth of Virginia

Employer Information Card

 

 

Agency Name

Questions?  Call First Script Customer Service at
800.791.2080

 

EMPLOYEE: Please complete the information below before giving this form to your pharmacist.

Name  

 

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Commonwealth of Virginia