Form Bwx514 - Medco By Mail Order Form (Page 2 of 2) in pdf

You may have a balance limit on your plan account. If you

Medco may generate automated calls to the telephone

do, once your unpaid balance exceeds that limit, no

number you have provided regarding the status of

additional orders will be processed until the balance is paid.

your prescription order. These automated calls provide

important information about your prescription order. If

You can call 1-800-948-8779 anytime to enroll in our

you would like to receive more information about these

automated payment plan, change the credit card on file,

automated calls, or you do not want to receive them,

check your account balance, or pay by phone using a

please call 1-800-391-9701 to speak with a Medco

credit card.

Member Services Representative.

Please take a minute to make sure…

Get more information from MyPharmacyPlus

• You have included your doctor’s signed prescription

Visit MyPharmacyPlus through the Pharmacy

form and filled out the patient information on the

section at

front of the order form for each new prescription.

• You have either filled out the credit card section on

To all Medicare beneficiaries whose private health Plan

the front of this order form or included a check or

has elected to be billed primary for Medicare Part B

money order for the required copayment.

covered drugs:

By choosing to use Medco By Mail to fill your prescription,

• You have written your Member ID on any check or

you are choosing to use the prescription drug coverage provided

money order.

by your group health plan. Medco will process your prescription

• The Medco address on the front shows through the

under your group health plan coverage, independent of

window of the return envelope.

the Medicare program, and no claim will be submitted to

Medicare. If you believe that Medicare may also provide coverage

• When you start Medco By Mail, you will receive a

and would like Medicare to pay for your prescription, you

Health, Allergy, and Medication Questionnaire. This

should go to a Medicare-participating pharmacy in your area.

information will help Medco better serve your

For a list of convenient Medicare-participating pharmacies,

prescription drug needs.

please call your local Medicare Carrier or 1-800-Medicare.

If you have any questions about the difference in coverage

Expedited shipping available

between your group health plan coverage and Medicare,

For an additional fee, your order will be shipped by an

please call Medco Member Services at 1-800-391-9701.

expedited service if offered to your area. This option must be

chosen when you make the order, and cannot be applied

after an order is already processed.

Additional Instructions

If you elect to have this and all future orders automatically

charged to your credit card by checking the box on the front

or enrolling by phone, bear in mind that the automated

payment plan feature will apply to all Medco By Mail orders.

Also note that we can only keep one credit card on record.

Premera Blue Cross Blue Shield of Alaska is an Independent Licensee of the Blue Cross Blue Shield Association.

FORM #BWX514

(07-2007)

Form Bwx514 - Medco By Mail Order Form Page 2

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