Form Hb42972m - 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.

Get more information from our website

Visit us at

•You have written your member ID number on any

check or money order.

To all Medicare beneﬁciaries whose private health plan

has elected to be billed primary for Medicare Part B

•The Medco address on the front shows through the

coverage:

window of the envelope marked "Medco By Mail

Order Center."

By choosing the Medco mail-order pharmacy to ﬁll your

prescription, you are choosing to use the prescription drug

•You have ﬁlled out the Health, Allergy & Medication

coverage provided by your group health plan. Medco will

Questionnaire. This information will help Medco

process your prescription under your group health plan

better serve your prescription drug needs.

coverage, independent of the Medicare program, and no claim

Expedited shipping available

will be submitted to Medicare. If you believe that Medicare

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

may also provide coverage and would like Medicare to pay for

expedited service offered in your area. This option must be

your prescription, you should go to a Medicare-participating

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

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

after an order has already been processed.

participating pharmacies, please call your local Medicare

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

Additional instructions

the difference in coverage between your group health plan

If you elect to have this and all future orders automatically

coverage and Medicare, please call 1-800-654-4216.

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

Florida law requires pharmacists to substitute a less

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

expensive, generically equivalent drug for certain brand-

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

name drugs unless you or your physician directs

that we can only keep one credit card on record.

otherwise.

FORM #HB42972M

Form Hb42972m - Medco By Mail Order Form Page 2

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