Mail Order Form (Page 2 of 3) in pdf

Patient/doctor Information continued

First name

Last name

Birth date(MM/DD/YYYY)

Sex

Patient's relationship to member

Self

Spouse

Dependent

Domestic partner

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

Self

Spouse

Dependent

Domestic partner

Doctor's last name

1st initial Doctor's phone number

Important reminders and other information

Check that your doctor has prescribed the maximum

Express Scripts will make all possible efforts,

days' supply allowed by your plan (not a 30-day supply),

as appropriate by law, to substitue generic

plus refills for up to 1 year, if appropriate. Also, ask your

formulations of medication, unless you or your

doctor or pharmacist about safe, effective and less

doctor specifically directs otherwise.

expensive generic drugs.

Pennsylvania and Texas laws permits

Complete the Health, Allergy and Medication

pharmacists to submit a less expensive generically

Questionnaire.

equivalent drug for a brand-name drug unless you

or your doctor directs otherwise. Check the box if

There may be a limit to the balance that you can carry

you do not wish a less expensive brand or

on your account. If this order takes you over the limit,you

generic drug.

must include payment. Avoid delays in processing by

Please note that this applies only to new

using e-checks or a credit-card. (See section 3 for

prescriptions and to any refills of that prescription.

details.)

For additional information, log in to

If you are a Medicare Part B beneficiary AND have

or call Member Services at

private health insurance,check your prescription drug

the number located on your ID card. TTY/TDD

benefit materials to determine the best way to get

users should call 1-800-759-1089.

Medicare Part B drugs and supplies. Or, call Member

Federal law prohibits the return of dispensed

Services at the number located on your ID card. To

controlled substances.

verify Medicare Part B prescription coverage, call

Medicare at 1.800.633.4227.

Mailing instructions

Your prescriptions or refill slips

Medco Health Solutions of

Using a business-size envelope,

Order form

Fairfield

send the following items to the

Health, Allergy & Medication

P.O. Box 747000

address shown on the right:

Questionnaire

Cincinnati, OH 45274-7000

Your payment

Do not use staples or paper

E-check enrollment form (optional)

clips.

NMSFNP1W

REV 05/09

Mail Order Form Page 2

Related Articles

Related forms

Related Categories