Mail Order Form Formed Co

Medco Pharmacy MAIL-ORDER FORM
*6101*
Please send me e-mail notices about the status of the enclosed prescription(s) and online ordering at: _________________________@_____________________.____________
Member information: Please verify or provide Member information below.
Member ID: Group: UTSYSRX

Name: Street Address: Street Address: Street Address: City, ST, ZIP:
New shipping address:
FOLD HERE
(Medco will keep this address on le for all orders from this membership until another shipping address is provided by any person in this membership.)
Daytime phone:
Evening phone:
Patient/doctor information: Complete one section for each person with a prescription. If a person has prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on back). Send all prescriptions in the envelope provided. Last name Sex M Patients relationship to member Self Spouse Dependent 1st initial Last name Sex M Patients relationship to member Self Spouse Dependent 1st initial Doctors phone number Doctors phone number
First name Birth date (MM/DD/YYYY) Doctors last name First name Birth date (MM/DD/YYYY) Doctors last name FOLD HERE
Complete your order: You can pay by e-check, check, money order, or credit card. Make checks and money orders payable to Medco Health Solutions, Inc., and write your member ID number on the front. You can enroll for e-check payments and price medications at www.medco.com, or call 1 800 818-0155.
Number of prescriptions sent with this order: Payment options: e-check Payment enclosed Amex Diners Credit card Send bill
For credit card payments: Visa MC Discover Expiration date M M Y Y
Credit card number
X Cardholder signature
I authorize Medco to charge this card for all orders from any person in this membership.
HG4559B
Mailing instructions are provided on the back of this form.
Patient/doctor information continued First name Birth date (MM/DD/YYYY) Doctors last name First name Birth date (MM/DD/YYYY) Doctors last name Important reminders and other information
Check that your doctor has prescribed the maximum days supply allowed by your plan (not a 30-day supply), plus rells for up to 1 year, if appropriate. Also, ask your doctor or pharmacist about safe, effective, and less expensive generic drugs. Complete the Health, Allergy & Medication Questionnaire. There may be a limit to the balance that you can carry on your account. If this order takes you over the limit, you must include payment. Avoid delays in processing by using e-checks or a credit card. (See Section 3 for details.) If you are a Medicare Part B beneciary AND have private health insurance, check your prescription drug benet materials to determine the best way to get Medicare Part B drugs and supplies. Or, call Member Services at 1 800 818-0155. To verify Medicare Part B prescription coverage, call Medicare at 1 800 MEDICARE (1 800 633-4227). Medco will make all possible efforts, as appropriate by law, to substitute generic formulations of medication, unless you or your doctor specically directs otherwise. c Pennsylvania and Texas laws permit pharmacists to substitute a less expensive generic equivalent for a brand-name drug unless you or your doctor directs otherwise. Check the box if you do not wish a less expensive brand or generic drug. Please note that this applies only to new prescriptions and to any rells of that prescription. For additional information, log in to www.medco.com or call Member Services at 1 800 818-0155. TTY/TDD users should call 1 800 759-1089. Federal law prohibits the return of dispensed controlled substances.
Last name Sex M Patients relationship to member Self Spouse Dependent 1st initial Last name Sex M Patients relationship to member Self Spouse Dependent 1st initial Doctors phone number Doctors phone number
FOLD HERE
FOLD HERE Place your prescription(s), this form, and your payment in the envelope provided. Be sure the Medco address shows through the window. Do not use staples or paper clips.
MEDCO HEALTH SOLUTIONS OF FORT WORTH PO BOX 650322 DALLAS, TX 75265-0322

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Medco Pharmacy MAIL-ORDER FORM

Member information: Please verify or provide Member information below.

Member ID: Group: UTSYSRX

New shipping address:

For credit card payments: Visa MC Discover Expiration date M M Y Y

Credit card number

Mailing instructions are provided on the back of this form.

MEDCO HEALTH SOLUTIONS OF FORT WORTH PO BOX 650322 DALLAS, TX 75265-0322

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