Form Hh8674b - Medco Pharmacy Mail-Order Form - Local Page 2
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2Patient/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
Sex
Patient’s relationship to member
Birth date (MM/DD/YYYY)
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. Also, 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, Allergy & 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. Avoid 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.
Please take a minute to make sure that you have either
For additional information or help, visit our
filled out the credit card section on the front of this order
website via or call Member Services at
form or included a check or money order for the required
1-800-903-8346.
co-payment. If you elect to have this and all future orders
automatically charged to your credit card, bear in mind that
Federal law prohibits the return of dispensed controlled
the automated payment plan feature will apply to all mail
substances.
orders.
The Medco Pharmacy is now a part of the
Express Scripts family of pharmacies.
Place your prescription(s), this form, and your
payment in the envelope provided. Do not use
staples or paper clips.
MEDCO HEALTH SOLUTIONS OF FAIRFIELD
PO BOX 6575
CINCINNATI, OH 45273-7983
HH8674B
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