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Medco By Mail Order Form
Benefits Provided by Medco
For New Prescriptions
To order by mail: Include your refill slip(s) with this form. Do not Fill out one line of the Patient Information section for each new complete the Patient Information section for refills. prescription you send. Be sure to include the patient's full name, For All Mail Orders
date of birth, and address, along with the doctor's name and Place all prescriptions and refill slips together with this completed order form and your co-payment into a standard, white, business- For Refills
size envelope. Write or type the address of the mail service To order from our website: www.medco.com. Have your
pharmacy on the front of the envelope and mail to Medco. The member ID number and prescription (Rx) number on hand. Your address can be found on the “forms and cards” page of our If You Need Additional Help
12-digit prescription or Rx number can be found on your refill slip. To order by phone: Call 1 800 4REFILL (1 800 473-3455) to use
If You Need Additional Help
the automated refill system. Have your member ID number and Call Member Services at the toll-free number on your ID card. The refill slip with the prescription information ready. best times to call are Tuesday through Friday afternoons. See the second page of this form for additional instructions. FOLD BACK HERE
Member Information
Member ID: ___________________________________________________

Shipping address if different from your mailing address
_______________________________________________________
Name: __________________________________________________Street Address: ____________________________________________Street Address: ____________________________________________Street Address: ____________________________________________City, ST, ZIP: ______________________________________________ Patient Information—complete one line for each new prescription (Do not complete for refills)
FOLD BACK HERE
Order Information
Paying by credit card?
Total number of medications in this order
(including all refills and new medications)
Subtotal of this order
Optional expedited shipping
$9.00 (subject to change)
Check here to have all orders billed to your credit card.
By doing so, you authorize Medco to keep your card number on file
Total enclosed
and bill all future orders and any outstanding balances directly to your credit card. To enroll by phone, please call 1 800 948-8779. Paying by check? Write your member ID number on your check or
money order made payable to Medco.
Reminder: To maximize your savings, ask
Please be sure address
is visible through window

your doctor for a 90-day supply (not a 30-day) of envelope marked
with refills up to one year as appropriate. You "Medco By Mail Order Center"
will always be charged the mail-order copay/coinsurance when you send a prescription tothe mail-order pharmacy.
Please take a minute to make sure.
You may have a balance limit on your plan account. If so, your unpaid balance exceeds that limit, no additional orders once your unpaid balance exceeds that limit, no additional • You have included your doctor's signed prescription
ocessed until the balance has been paid. ders will be processed until the balance has been paid.
form and filled out the patient information on the
front of the order form for each new prescription.

You can call 1 800 948-8779 anytime to enroll in our automated payment plan, change the credit card on file, check • You have either filled out the credit card section on
your account balance, or pay by phone using a credit card. the front of this order form or included a check or
money order for the required co-payment.

Get more information from our website
• You have written your member ID number on any
V sit us at www
.medco.com
.medco.com to check the status of your
check or money order.
To all Medicar
e beneficiaries whose private health plan
efill medications, obtain valuable health and medica- • You have filled out the Health and Medication
has elected to be billed primary for Medicar
Visit us at www.medco.com
Questionnaire. This information will help Medco
coverage:
To all Medicare beneficiaries whose private health plan
better serve your prescription drug needs.
By choosing the Medco mail-order pharmacy to fill your has elected to be billed primary for Medicare Part B
prescription, you ar
coverage:
Expedited shipping available
coverage provided by your group health plan. Medco will By choosing the Medco mail-order pharmacy to fill your For an additional fee, your order will be shipped by an process your prescription under your group health plan prescription, you are choosing to use the prescription drug expedited service offered in your area. This option must be coverage, independent of the Medicare program, and no claim coverage provided by your group health plan. Medco will chosen when you make the order, and it cannot be applied will be submitted to Medicare. If you believe that Medicare process your prescription under your group health plan may also provide coverage and would like Medicare to pay for coverage, independent of the Medicare program, and no claim Additional instructions
your prescription, you should go to a Medicare-participating will be submitted to Medicare. If you believe that Medicare pharmacy in your area. For a list of convenient Medicare- If you elect to have this and all future orders automatically may also provide coverage and would like Medicare to pay for participating pharmacies, please call your local Medicare charged to your credit card (by checking the box on the front your prescription, you should go to a Medicare-participating carrier or 1 800 MEDICARE. If you have any questions about or enrolling by phone), bear in mind that the automated pharmacy in your area. For a list of convenient Medicare- the difference in coverage between your group health plan payment plan feature will apply to all mail orders. Also note participating pharmacies, please call your local Medicare coverage and Medicare, please call the number on your ID that we can only keep one credit card on record at any time. carrier or 1 800 MEDICARE. If you have any questions about the difference in coverage between your group health plan
coverage and Medicare, please call the number on your ID
card .
Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help us provide your prescription drug benefit services including, for example, filling prescriptions and alerting your doctor about possible medication problems. To best serve you, we need to know if you have any known allergies, conditions or diseases.
• Please complete the questionnaire for each person in the household eligible for pharmacy benefits with Medco By Mail.
• If you need additional forms you may copy this form or call your Member Services toll free number.
Please remember to print your group and member number on both pages.
Return this questionnaire with your prescription or refill order form.
Section 1: Member Identification and Contact (Group and Member number required on all pages)
Group Number
Member Number (Located on your pharmacy
Daytime Telephone Number
benefit card and/or in your benefits information)
Member/Subscriber First name
Last Name
Street Address/Apt No.
Section 2: Drug Allergy Conditions
For each covered family member, include their first name, date of birth and gender.
For each family member fill in the circle ONLY if an allergy or bad reaction happened anytime in the past.
If your allergy is not listed, please print the name of the medication allergy in the bottom section of this chart.
Correct way to mark circles: z
Please use blue or black ink.
Please add last name if different than member
Dependent Dependent Dependent
First Name:
Date of Birth (MM/DD/CCYY):
Penicillin/cephalosporin antibiotics (e.g. ampicillin, Erythromycin, Biaxin®, Zithromax® Non-steroidal anti-inflammatory drugs (NSAIDs) If there is a drug allergy to report and not listed above, please print the name of the drug in the space. Example: morphine Medco is a registered trademark of Medco Health Solutions, Inc. Copyright 2005 Medco Health Solutions, Inc.
All Rights Reserved 04/2005-gt
Please complete both pages and staple together.
Group Number
Member Number
Section 3: Medical Conditions
Please list names of each family member enrolled in the appropriate column. Then for each family member, fill in the circle
next to each condition if a doctor ever said that this particular family member has that condition.
Dependent Dependent Dependent
First Name:
High blood pressure (hypertension)
High cholesterol (hypercholesterolemia)
Chronic bronchitis or emphysema (COPD)
Allergies, runny nose, hay fever (allergic rhinitis)
High blood sugar (diabetes)
Gastric reflux, heartburn or esophagitis (GERD)
Inflammatory bowel disease (colitis, Crohn’s disease)
High pressure in the eyes (glaucoma)
Poor circulation in the legs (peripheral vascular disease) Enlarged prostate (benign prostatic hyperplasia, BPH)
Print other medical conditions not listed above in the space provided. Example - glaucoma For more information about Medco, please visit us online at www.medco.com.
Please complete both pages and staple together. Please return the questionnaire with your prescription or refill order form.

Source: http://www.schoolcraft.edu/docs/default-source/hr/BCBSM_Medco_Mail_Order.pdf

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Enrolment Form and Terms and Conditions Section 1- Child details Examples are shown in italics in the right hand column *PLEASE ATTACH A COPY OF YOUR CHILD'S CLINIC CARD Section 2 – Parent (No 1) Details Section 3 – Parent (No 2) Details Section 4 – Family member not living with you – Details NO PERSON MAY COLLECT YOUR CHILD IF YOU HAVE NOT MADE ARRA

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Page 1 of 2 IN THIS ISSUE: NEW: Updates to the Canadian Immunization Guide REMINDER: Ontario Drug Benefit Coverage for Smoking Cessation Medications and Counselling UPDATE: Novel Coronavirus NEW: Updates to the Canadian Immunization NEW: Expanded Role of Pharmacists in Smoking Cessation Programming The National Advisory Committee on Immunization a

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