Form Hbc53 - Home Delivery Form (Hmq Questionnaire) Page 2
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4Patient/doctor information continued
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to member
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
Important reminders and other information
Check that your doctor has prescribed the maximum days’
Express Scripts will make all possible efforts, as
supply allowed by your plan (not a 30-day supply), plus
appropriate by law, to substitute generic formulations
refills for up to 1 year, if appropriate. lso, ask your doctor
of medication, unless you or your doctor specifically
or pharmacist about safe, effective, and less expensive
directs otherwise.
generic drugs.
Pennsylvania and Texas laws permit pharmacists to
Complete the Health, llergy & Medication Questionnaire.
substitute a less expensive generic equivalent for a
brand-name drug unless you or your doctor directs otherwise.
There may be a limit to the balance that you can carry
Check the box if you do not wish a less expensive
on your account. If this order takes you over the limit, you
brand or generic drug.
must include payment. void delays in processing by using
Please note that this applies only to new prescriptions and to
e-checks or a credit card. (See Section 3 for details.)
any refills of that prescription.
If you are a Medicare Part B beneficiary ND have
For additional information or help, visit us at
private health insurance, check your prescription drug
or call Member Services at the phone
benefit materials to determine the best way to get
number found on your ID card. TTY/TDD users should call
Medicare Part B drugs and supplies. Or, call Member
1.800.759.1089.
Services at the phone number found on your ID card. To
verify Medicare Part B prescription coverage, call
ederal law prohibits the return of dispensed controlled
Medicare at 1.800.633.4227.
substances.
Place your prescription(s), this form, and your
payment in the envelope provided. Be sure the
address shows through the window. Do not use
staples or paper clips.
EXPRESS SCRIPTS
PO BOX 747000
CINCINNATI, OH 45274-7000
MLRFOHNW
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