Aetna Rx Home Delivery Form printable pdf download

Medication Order Form

Aetna Rx Home Delivery

Mail this form to:

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AETNA RX HOME DELIVERY

PO BOX 417019

KANSAS CITY MO 64179-7019

Member ID # (if not shown or if different from above)

Prescription Plan Sponsor or Company Name

Instructions:

Please use blue or black ink and print in capital letters. Fill in both sides of this form.

New Prescriptions - Mail your new prescriptions with this form.

Number of New prescriptions:

Reﬁlls - Order by Web, phone, or write in Rx number(s) below.

Number of Reﬁll prescriptions:

To get your order sooner: Request refills or new prescriptions online at or call

toll-free 1-844-741-8423, TTY 711.

Shipping Address. To ship to an address different from the one printed above, enter the changes here.

Last Name

First Name

Suffix (JR, SR)

Street Address

Apt./Suite #

Use shipping address

for this order only.

City

State

ZIP Code

Daytime Phone #:

Evening Phone #:

Reﬁlls. To order mail service refills, enter your prescription number(s) here.

Aetna wants to provide you with high quality medicines at the best possible price. In order to do this, we will substitute

equivalent generic medicines for Brand name medicines whenever possible. If you do not want us to substitute

generics, please provide specific instructions including drug names, use the “Special instructions” section of this form.

All claims for prescriptions sent to Aetna Rx Home Delivery using this form will be submitted to your prescription

benefit plan for payment. If you do not want them submitted to your plan, do not use this form. You may call Customer

Care to make alternate arrangements for submission of your order and payment.

We may package all of these prescriptions together unless you tell us not to.

Please Note: By submitting this form you verify that the information is correct, that the prescriptions

enclosed are for use by eligible participants and authorize the release of all information to the Plan

Sponsor, administrator, or underwriter. All communications regarding this account will be directed to the

member (employee/retiree). If a spouse or other eligible dependent wishes to direct their communications

to an alternate address or telephone number, they may make this request by completing the Confidential

Communications Request form provided in the Privacy Notice, or as available on our website.

Aetna Rx Home Delivery Form