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Medco prescription mail order form
1 Member information:
Please verify or provide Member information below.
c Please send me e-mail notices about the status of the enclosed
prescription(s) and online ordering at: _________________________@_______________________.______
(Medco will keep this address on file for all orders from this
membership until another shipping address is provided by any person in this membership.)
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 sections are on back). Send all prescriptions in the envelope provided.
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 member ID number on the front. You can enroll for
e-check payments and price medications at www.medco.com
, or call 1 800 939-3212.
Number of prescriptions sent with this order:
e-check Payment enclosed Credit card Send bill
For credit card payments:
I authorize Medco to charge this card for all
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.
Mailing instructions are provided on the back of this form.
Patient/doctor information continued
Important reminders and other information
that your doctor has prescribed the maximum days’
Medco will make all possible efforts, as appropriate by
supply allowed by your plan (not a 30-day supply), plus
law, to substitute generic formulations of medication,
refills for up to 1 year, if appropriate. Also, ask your doctor
unless you or your doctor specifically directs otherwise.
or pharmacist about safe, effective, and less expensive
c Pennsylvania and Texas laws permit pharmacists to
substitute a less expensive generic equivalent for a
the Health, Allergy & Medication Questionnaire.
brand-name drug unless you or your doctor directs otherwise.
There may be a limit to the balance
that you can carry
Check the box if you do not wish a less expensive
on your account. If this order takes you over the limit, you
brand or generic drug.
must include payment. Avoid delays in processing by using
Please note that this applies only to new prescriptions and to
e-checks or a credit card. (See Section 3 for details.)
If you are a Medicare Part B beneficiary AND have
For additional information
or help, visit us at
private health insurance,
check your prescription drug
or call Member Services at
benefit materials to determine the best way to get
1 800 939-3212. TTY/TDD users should call 1 800 759-1089.
Medicare Part B drugs and supplies. Or, call Member
Services at 1 800 939-3212. To verify Medicare Part B
Federal law prohibits the return of dispensed controlled
prescription coverage, call Medicare at 1 800 MEDICARE
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
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. Medco complies with federal privacy regulations and will protect this information.
Complete and return this form following the steps below or go to www.medco.com/healthform to submit it online:
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 preaddressed envelope marked HMQ. Do not send prescriptions,
refill slips, or correspondence with this questionnaire. If you do not have a preaddressed envelope, please return the
Medco HMQ QuestionnaireP.O. Box 14238Lexington, KY 40512
SECTION 1: Patient information
Member number:(Located on your member ID card and/or in your benefit information.)
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
FOR OFFICE USE ONLY
of birth: Month
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)
FOR OFFICE USE ONLY
SECTION 4: Your nonprescription medications
Fill in the oval completely for each nonprescription medication that you are currently taking on a regular basis.
FOR OFFICE USE ONLY
Additional health information
If you have any other medication allergies, medical conditions, or nonprescription medications notlisted above, please call 1 877 438-4417.
Did you complete both sides?
Thank you very much.
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