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Medco Pharmacy™
MAIL-ORDER FORM
1 Customer information: Please verify or provide customer information below.
Please send me e-mail notices about the status of the Subscriber #:
enclosed prescription(s) and online ordering at: Rx Grp #:
(Medco will keep this address on file for all orders from this subscriber until another shipping address is provided by any 2 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 sectionsare on back). Send all prescriptions in one envelope.
3 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 subscriber ID number
on the front. You can enroll for e-check payments and price medications by calling 1-800-948-8779.
Number of prescriptions sent with this order:
Payment options:
For credit card payments:
I authorize Medco to charge this card for all orders from any person in this plan.
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.
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X00000-00000-000-0000 7/06
Mailing instructions are provided on the back of this form.
Patient/doctor information continued
First name
Important reminders and other information
Ask your doctor to write your prescription for a 90-day Medco will make all possible efforts, as
supply with refills when appropriate. You will be charged appropriate by law, to substitute generic
a mail-order co-payment, regardless of the days’ supply formulations of medication, unless you or your
written on the prescription. Please be sure that your doctor specifically directs otherwise.
doctor writes your prescription for a 90-day supply, not Pennsylvania and Texas laws permit pharmacists to substitute a less expensive generic equivalent for a Complete the Health, Allergy & Medication Questionnaire.
brand-name drug unless you or your doctor directs
otherwise. Check the box if you do not wish a
There may be a limit to the balance that you can carry
less expensive brand or generic drug.
on your account. If this order takes you over the limit, youmust include payment. Avoid delays in processing by Please note that this applies only to new prescriptions using e-checks or a credit card. (See Section 3 for details.) and to any future refills of that prescription.
If you are a Medicare Part B beneficiary AND have
For additional information or help, call the Customer
private health insurance, check your pharmacy
Care number on your ID card. TTY/TDD users should call benefit materials to determine the best way to get Medicare Part B medications and supplies. Or, call theCustomer Care number on your ID card. To verify Federal law prohibits the return of dispensed Medicare Part B prescription coverage, call Medicare Mailing instructions: Place your prescription(s), this form, and your payment in an envelope addressed to:
MEDCO HEALTH SOLUTIONS OF FAIRFIELD
P.O. BOX 747000
CINCINNATI OH 45274-7000
PD903991
Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects.
We will alert your pharmacist about possible drug allergies and interactions that can be harmful. To best serve you, weneed to know if you have any medication allergies or medical conditions. We also need to know what prescription andnonprescription medications you take regularly.
Your privacy is important to us. We comply with federal privacy regulations and will protect this information.
Follow the steps listed below.
Step 1: Verify and complete information in SECTION 1.
Step 2: Complete all sections below using blue or black ink. Please print.
Step 3: Return the completed questionnaire in the self-addressed envelope with your mail-order form or refills. If you
do not have a preaddressed envelope, please return the questionnaire to:
Medco Health Solutions, Inc.
4865 Dixie HighwayFairfield, OH 45014Attn: HMQ SECTION 1: Patient information
Patient member number:(Located on your ID card.) SECTION 2: Your medication allergies
Fill in the oval completely if you have had an allergy or serious reaction to any of these medications:
Aspirin and salicylates (for example: ZORprin®, Trilisate®)Codeine (for example: Tylenol® #3)Erythromycin, Biaxin®, Zithromax®Nonsteroidal anti-inflammatory drugs (NSAIDS) (for example: ibuprofen, Advil®, Motrin®)Penicillins/cephalosporins (for example: Amoxil®, amoxicillin, ampicillin, Keflex®, cephalexin) Sulfa drugs (for example: Septra®, Bactrim®, TMP/SMX)Tetracycline antibiotics If you have an allergy to a medication that is not listed above, print the name of that medication in the space below. Example: morphineother: PD903991
SECTION 3: Your medical conditions
Has your doctor ever told you that you have any of the conditions listed below? If so, fill the oval completely next to all that apply.
Hemophilia and hemophilia-like conditions Bladder control problem (urinary incontinence) Enlarged prostate (benign prostatic hyperplasia, Gastric reflux, heartburn, or esophagitis (GERD) If you have a medical condition that is not listed above, print the name of that medical condition in thespace below. Example: breast cancer SECTION 4: Your nonprescription medications
Fill in the oval completely for each nonprescription medication that you are currently taking on a regular basis.
If you take a nonprescription medication that is not listed above, print the name of that medication inthe space below.
SECTION 5: Patient prescription medications*
Please list the prescription medications you are currently taking in the space below. *Information
can be found on the prescription labels. If none, please check here. [ ] NONE
Did you complete both sides?
Thank you very much.
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Source: http://www.cityoflakewales.com/hr/UHCMailOrder.pdf