Microsoft word - 4979 online.rtf

Mail Service Pharmacy Tips
Walgreens Mail Service
Illinois Comprehensive Health
• Complete attached registration form. You may also register yourself (and dependents, if applicable) at Insurance Plan
REGISTRATION & PRESCRIPTION ORDER FORM
• New prescriptions must be mailed to the mail Use black ink only. Enclose form with prescription(s) and payment. PARTICIPANT INFO.
Suffix extension † Patient needs snap-on caps • For long-term medications you need right away: ask your doctor for two prescriptions—one for a small supply to fill at a participating retail pharmacy, and one for a long-term supply to fill through the mail. • If two or more prescriptions are sent in for multiple family members, the prescriptions will be shipped, as a single order, to an adult family member at the Shipping Address (Please do not use P.O. Box) address given on the order form. If you prefer different shipping arrangements for privacy or other reasons, please contact our Customer Care Center. • Most orders are shipped by U.S. Postal Service. Controlled substances may require an adult signature upon receipt. Packaging does not show ALLERGIES:
any indication that medications are enclosed. HEALTH CONDITIONS:
• Emergency prescriptions can be shipped overnight. • Include payment, if applicable to avoid any delays. PAYMENT – CHECK OR CREDIT CARD (VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS)
It is standard pharmacy practice to substitute Rx Type • Make checks payable to Walgreens Mail Service. generic equivalents for brand-name drugs whenever possible. Walgreens Mail Service will • Refills cannot be transferred from other dispense an FDA-approved generic equivalent pharmacies. Request a new prescription from your whenever available, permitted by your prescriber, and allowable by law. If you do not want a Customer Care Center:
generic equivalent, please call our Customer 1-888-265-1807 (TTY: 1-800-573-1833)
Monday–Friday, 8:00 a.m. – 10:00 p.m. (Eastern) Saturday–Sunday, 8:00 a.m. – 5:00 p.m. (Eastern) Refills by Phone:
Internet:
Mail to: Walgreens Mail Service P.O. Box 29061, Phoenix, AZ 85038-9061 Turn page and complete dependent info. on the other side of this form.
DEPENDENT INFO. Suffix
Shipping Address (if different than participant) ALLERGIES:
HEALTH CONDITIONS:
DEPENDENT INFO. Suffix
Shipping Address (if different than participant) ALLERGIES:
HEALTH CONDITIONS:
Please Note: By submitting this form, you have authorized
Customer Care Center:
release of all information to Walgreens Mail Service (and other necessary parties) as required to process your prescriptions and their refills under your benefit plan. Monday-Friday, 8 a.m. – 10 p.m. (Eastern) Saturday-Sunday, 8 a.m. – 5 p.m. (Eastern)

Source: https://www.chip.state.il.us/downloads/WHI4979online.pdf