Form Hb27088m - Medco By Mail Order Form (Page 2 of 2) in pdf

Please take a minute to make sure...

You may have a balance limit on your plan account. If so, once

your unpaid balance exceeds that limit, no additional orders

• You have included your doctor's signed prescription

will be processed until the balance has been paid.

form and ﬁlled out the patient information on the

front of the order form for each new prescription.

You can call 1 800 948-8779 anytime to enroll in our

automated payment plan, change the credit card on ﬁle, check

• You have either ﬁlled out the credit card section on

your account balance, or pay by phone using a credit card.

the front of this order form or included a check or

money order for the required co-payment.

Florida law requires pharmacists to substitute a less expensive,

generically equivalent drug for certain brand-name drugs

• You have written your member ID number on any

unless you or your physician directs otherwise.

check or money order.

Get more information from our website

• The Medco address on the front shows through the

Visit us at

window of the envelope marked "Medco By Mail

Order Center."

To all Medicare beneﬁciaries whose private health plan

has elected to be billed primary for Medicare Part B

• You have ﬁlled out the Health and Medication

coverage:

Questionnaire. This information will help Medco

better serve your prescription drug needs.

By choosing the Medco mail-order pharmacy to ﬁll your

prescription, you are choosing to use the prescription drug

Expedited shipping available

coverage provided by your group health plan. Medco will

For an additional fee, your order will be shipped by an

process your prescription under your group health plan

expedited service offered in your area. This option must be

coverage, independent of the Medicare program, and no claim

chosen when you make the order, and it cannot be applied

will be submitted to Medicare. If you believe that Medicare

after an order is already processed.

may also provide coverage and would like Medicare to pay for

Additional instructions

your prescription, you should go to a Medicare-participating

pharmacy in your area. For a list of convenient Medicare-

If you elect to have this and all future orders automatically

participating pharmacies, please call your local Medicare

charged to your credit card (by checking the box on the front

carrier or 1 800 MEDICARE. If you have any questions about

or enrolling by phone), bear in mind that the automated

the difference in coverage between your group health plan

payment plan feature will apply to all mail orders. Also note

coverage and Medicare, please call 1 800 918-8523.

that we can only keep one credit card on record.

Form Hb27088m - Medco By Mail Order Form Page 2

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