Form Pd903991 - Medco Pharmacy Mail-Order Form Page 2
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4Patient/doctor information continued
First name
Last name
Birth date (MM/DD/YYYY)
Sex
Patient’s relationship to subscriber
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 subscriber
M
F
Self
Spouse
Dependent
Doctor’s last name
1st initial
Doctor’s phone number
Important reminders and other information
Ask your doctor to write your prescription for a 90-day
Medco will make all possible efforts, as
supply with refills when appropriate. You will be charged
appropriate by law, to substitute generic
a mail-order co-payment, regardless of the days’ supply
formulations of medication, unless you or your
written on the prescription. Please be sure that your
doctor specifically directs otherwise.
doctor writes your prescription for a 90-day supply, not
Pennsylvania and Texas laws permit pharmacists to
a 30-day supply with three refills.
substitute a less expensive generic equivalent for a
brand-name drug unless you or your doctor directs
Complete the Health, Allergy & Medication Questionnaire.
otherwise. Check the box if you do not wish a
There may be a limit to the balance that you can carry
less expensive brand or generic drug.
on your account. If this order takes you over the limit, you
must include payment. Avoid delays in processing by
Please note that this applies only to new prescriptions
using e-checks or a credit card. (See Section 3 for details.)
and to any future refills of that prescription.
If you are a Medicare Part B beneficiary AND have
For additional information or help, call the Customer
private health insurance, check your pharmacy
Care number on your ID card. TTY/TDD users should call
benefit materials to determine the best way to get
1-800-759-1089.
Medicare Part B medications and supplies. Or, call the
Federal law prohibits the return of dispensed
Customer Care number on your ID card. To verify
controlled substances.
Medicare Part B prescription coverage, call Medicare
at 1-800-MEDICARE (1-800-633-4227).
Mailing instructions:
Place your prescription(s), this form, and your payment in an envelope addressed to:
MEDCO HEALTH SOLUTIONS OF FAIRFIELD
P.O. BOX 747000
CINCINNATI OH 45274-7000
PD903991
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