Medication Record Form printable pdf download

Medication Record Form

CanaRxMeds is an optional mail order program for employees and their covered

INTRODUCTION:

dependents who are insured through the following West Suburban Health Group

plans: Network Blue Options HMO Rate Saver, Blue Cross Blue Shield Benchmark

Plan, Harvard Pilgrim HMO Rate Saver, Harvard Pilgrim Choicenet Benchmark

Plan, Tufts Health Plan EPO Rate Saver, or Tufts Health Plan Benchmark Plan.

When ordering your new medications, please allow 20 business days for delivery.

CO-PAYMENTS:

All member co-payments have been waived for this program only.

ORDERING

To place your order, we require a completed Medication Record Form, as well as a

prescription for each medication. Please ask your doctor to specify a 3-month

INSTRUCTIONS:

supply with 3 refills on each prescription. This will allow our Pharmacies to

automatically ship your medications after confirming your continued need.

COMPLETED MEDICATION RECORD FORMS MAY BE SUBMITTED BY:

FAXING TOLL FREE TO:

1-866-715-6337

MAILING TO:

CanaRx Group

P.O. Box 44650

Detroit, MI 48244-0650

NOTE: The Medication Record and the prescriptions should arrive together. If you

need to order new medications later in the year, you will need to send an updated

Medication Record; then simply have your doctor fax the prescription directly, with

your health plan number (from your card) written on the prescription.

PRESCRIPTIONS MAY BE SUBMITTED BY:

FAXING TOLL FREE TO:

1-866-715-6337

DIRECTLY FROM YOUR DOCTOR’S

OFFICE ONLY

MAILING TO:

CanaRx Group

P.O. Box 44650

Detroit, MI 48244-0650

SERVICE

Additional forms may be obtained from your employer, online at

INFORMATION:

, or by calling the myMedicationAdvisor

HelpLine at (877) 467-3113.

Thank you for participating in this program. Our goal is your total satisfaction.

Please do not hesitate to bring any questions or concerns to our attention.

Call CanaRxMeds at 1-866-893-6337.

Medication Record Form