Fillable Medication Order Form - Aetna printable pdf download

Medication Order Form - Aetna

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Medication Order Form

Aetna Rx Home Delivery

Mail this form to:

AETNA RX HOME DELIVERY

P.O. BOX 829518

302649609

PEMBROKE PINES, FL 33082-9518

Enter ID number

Prescription Plan Sponsor or Company Name

Please use blue or black ink, capital letters, and 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:

For Fastest Service, order refills at or call toll-free 1-888-RX AETNA (1-888-792-3862), or TDD (for hearing impaired)

at 1-800-823-6373. Your doctor may fax your prescription(s) to 1-877-270-3317. Only a doctor may fax a prescription.

Shipping Address.

Last Name

First Name

Suffix (JR, SR)

Street Name

Apt./Suite #

Use this 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.

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.