Form Hb906472 - Medical Mutual Medco By Mail Order Form (Page 2 of 2) in pdf

Please take a minute to make sure . . .

Additional Instructions

If you elect to have this and all future orders automatically

• You have included your doctor’s signed prescription

charged to your credit or debit card (by checking the box on

form and filled out the patient information on the

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

front of the order form for each new prescription.

automated payment plan feature will apply to all mail orders.

• You have either filled out the credit or debit card section

Also note that we can only keep one credit or debit card on

on the front of this order form or included a check or

record.

money order for the required copayment.

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

• You have written your member ID number on any check

once your unpaid balance exceeds that limit, no

or money order.

additional orders will be processed until the balance has been

paid.

• The Medco address on the front shows through the

window of the return envelope.

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

automated payment plan, change the credit or debit card on

• You have filled out the Health and Medication

file, check your account balance, or pay by phone using a

Questionnaire. This information will help Medco better

credit or debit card.

serve your prescription drug needs.

Ohio Law allows a less expensive, generically equivalent drug

Please Note: Be sure to review your prescription with your

to be substituted for certain brand-name drugs unless you or

doctor. For your convenience, your prescription benefit permits

your physician direct otherwise.

up to a 90-day supply, plus refills, as appropriate of medications

you fill through Medco by Mail. To take advantage of this

service, you must ask your doctor to write your prescriptions for

Get more information from our website

up to a 90-day supply, plus refills, as appropriate for you. In

Visit us at

most circumstances, your mail order copayment will be the

same whether your prescription is written for a 90-day or less

than a 90-day supply.

To all Medicare beneficiaries whose private health plan

has elected to be billed primary for Medicare Part B

Expedited shipping available

covered drugs:

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

expedited service offered in your area. This option must be

By choosing the Medco mail-order pharmacy to fill your

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

prescription, you are choosing to use the prescription drug

after an order has already been processed.

coverage provided by your group health plan. Medco will

process your prescription under your group health plan

coverage, independent of the Medicare program, and no

claim will be submitted to Medicare. If you believe that

Medicare may also provide coverage and would like Medicare

to pay for your prescription, you should go to a Medicare-

participating pharmacy in your area. For a list of convenient

Medicare-participating pharmacies, please call your local

Medicare carrier or 800/MEDICARE. If you have any

questions about the difference in coverage between your

group health plan coverage and Medicare, please call

800/417-1961.

FORM #HB906472

MMO#Z5287

Form Hb906472 - Medical Mutual Medco By Mail Order Form Page 2

Related Articles

Related forms

Related Categories