Rx group number BCBSMRX1 prescription drug mail order form (PDF)

Medco Pharmacy ®MAIL-ORDER FORM*6101*FOLD HERE FOLD HERE13Member information: Please verify or provide Member information below.Member ID:Group: BCBSMRx1Name:Street Address:Street Address:Street Address:City, ST, ZIP:Daytime phone:2Complete your order: You can pay by e-check, check, money order, or credit card. Make checks and moneyorders payable to Express Scripts, and write your member ID on the front. You can enroll for e-checkpayments and price medications at our website via bcbsm.com, or call 1-800-903-8346.Number of prescriptions sent with this order:New shipping address:(Express Scripts will keep this address on file for all orders fromthis membership until another shipping address is provided byany person in this membership.)Evening phone:Patient/doctor information: Complete one section for each person with a prescription. If a person hasprescriptions from more than one doctor, complete a new section for each doctor (additional sections are onback). Send all prescriptions in the envelope provided.First nameBirth date (MM/DD/YYYY)Doctor’s last nameFirst nameBirth date (MM/DD/YYYY)Doctor’s last nameSexMSexMFFLast namePatient’s relationship to memberSelf Spouse DependentLast namePlease send me e-mail notices about the status of the enclosedprescription(s) and online ordering at:@ .1st initialPatient’s relationship to memberSelf Spouse Dependent1st initialDoctor’s phone numberDoctor’s phone numberPayment options: e-check Payment enclosed Credit card Send billFor credit card payments:Visa MC Discover Amex DinersExpiration dateXM M Y Y Cardholder signatureCredit card numberI authorize Express Scripts to charge this card forall orders from any person in this membership.Rush the mailing of this shipment ($15, cost subject to change). NOTE: This will only rush the shipping,not the processing of your order. Street address is required; P.O. box is not allowed.HH8674BExpress Scripts is an independent company that provides mail-order pharmacy services for Blue Cross Blue Shield of Michigan

Patient/doctor information continuedFirst nameLast nameBirth date (MM/DD/YYYY)SexMFPatient’s relationship to memberSelf Spouse DependentDoctor’s last name1st initial Doctor’s phone numberFirst nameLast nameFOLD HERE FOLD HEREBirth date (MM/DD/YYYY)Doctor’s last nameSexMImportant reminders and other informationCheck that your doctor has prescribed the maximum days’supply allowed by your plan (not a 30-day supply), plusrefills for up to 1 year, if appropriate. Also, ask your doctoror pharmacist about safe, effective, and less expensivegeneric drugs.Complete the Health, Allergy & Medication Questionnaire.There may be a limit to the balance that you can carryon your account. If this order takes you over the limit, youmust include payment. Avoid delays in processing by usinge-checks or a credit card. (See Section 3 for details.)Please take a minute to make sure that you have eitherfilled out the credit card section on the front of this orderform or included a check or money order for the requiredco-payment. If you elect to have this and all future ordersautomatically charged to your credit card, bear in mind thatthe automated payment plan feature will apply to all mailorders.FPatient’s relationship to memberSelf Spouse Dependent1st initialDoctor’s phone numberExpress Scripts will make all possible efforts, asappropriate by law, to substitute generic formulationsof medication, unless you or your doctor specificallydirects otherwise.Pennsylvania and Texas laws permit pharmacists tosubstitute a less expensive generic equivalent for abrand-name drug unless you or your doctor directs otherwise.Check the box if you do not wish a less expensivebrand or generic drug.Please note that this applies only to new prescriptions and toany refills of that prescription.For additional information or help, visit ourwebsite via bcbsm.com or call Member Services at1-800-903-8346.Federal law prohibits the return of dispensed controlledsubstances.The Medco Pharmacy is now a part of theExpress Scripts family of pharmacies.Place your prescription(s), this form, and yourpayment in the envelope provided. Do not usestaples or paper clips.HH8674BMEDCO HEALTH SOLUTIONS OF FAIRFIELDPO BOX 6575CINCINNATI, OH 45273-7983