Mail Service Order Form - Caremark Page 2
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1
2New Prescription
Enclose original doctor-signed prescription(s) and payment with this form. Ask your doctor to
2
Information
write your mail service prescription for the maximum supply allowed by your plan (if appropriate).
Primary
Spouse of
Prescriptions are for:
Other Dependent(s)
Plan Participant
Plan Participant
Total number of medicines in this order:
Doctor Name (LastName)
(FirstName)
Doctor Phone Number
(
)
Do not contact my doctor for approval to change my prescription to a preferred medicine. Your benefit plan
sponsor may consider certain medicines to be“non-preferred”or ”non-formulary”. Usually, this means that there is another
medicine that may work the same way and do the same thing, but may be less expensive. As a service to you, we may
contact your doctor for approval to dispense the alternate medicine, if one exists. If you mark this oval, Caremark will not
contact your doctor for approval to change your medicine.
Mark here if you want your mail service materials printed in Spanish.
Mark here for easy open caps, if available.
Caremark wants to provide you with high quality medicines at the best possible price. In order to do this, we will substitute
generic medicines for brand name medicines whenever possible. If you do not want us to substitute generics, please provide
specific instructions, including drug names, in the “Comments”section below.
Comments:
Your order will be shipped standard delivery at no charge. Please allow
2nd Business
Shipping/
3
Day = $13 (per order)
Payment
14 days from the date you mail your order for delivery of your medicine.
Information
If you prefer expedited delivery, mark the appropriate oval. Expedited
Next Business
shipping only affects shipping time, not processing time of your order.
Day = $18 (per order)
All medicines in this order will be sent in the same package to the address provided. If a family member does not
want his or her medicine sent in the same package as that of other family members, he or she should complete a
separate order form.
Payment, when applicable, is due with each order and may be made by credit card, check or money order. Payment
by credit card is preferred. If paying by check, make the check payable to Caremark. Please write your Plan Participant
identification number on your check. There is a $20 returned check charge. Do not send cash. Orders received without
payment may result in a delay of processing. Any outstanding balances will be the responsibility of the primary insured.
If you have questions about your payment amount, call the number on your prescription card or the phone number
printed on the front of this form, if available.
Credit Card (provide information below)
Payment by Check or Money Order
MasterCard
Visa
Discover
American Express
Exp. Date
Credit Card #
(MM-YYYY)
Credit Cardholder Signature
This credit card will be billed for medicine costs, expedited shipping (if applicable) and any outstanding balances. It will also
be billed for all future orders, unless you provide a different form of payment.
By returning this form to Caremark, you consent to the use and release of your health information and that of your
covered dependents (if you are their guardian or authorized representative) to your health plans and healthcare
providers/agents for health benefits management.
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