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Usw351.org

MEDCO BY MAIL
ORDER FORM
Member Information Please verify or provide member information below.
❏ Please send me e-mail notices about the status of the Member ID:
enclosed prescription(s) and online ordering at: Group:
(Medco will keep this address on file for all orders from this membership until another shipping address isprovided by any person in this membership.) Daytime phone:
Evening phone:
Patient/doctor Information Fill out a separate section for each person requesting a prescription fill. If
he/she has more than one prescription from the same doctor, complete just one section but include allprescriptions in the envelope provided. If a person has prescriptions from more than one doctor, complete a newsection for each doctor and include all prescriptions. Additional patient/doctor space is provided on the next page.
❏Spouse ❏Dependent ❏Domestic partner ❏Spouse ❏Dependent ❏Domestic partner 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. To
enroll for e-check payments, complete and return the e-check form (fifth page printed) with your order.
Number of prescriptions sent with this order:
Payment options: ❏e-check ❏Payment enclosed
For credit card payments:
❏Visa ❏MC ❏Discover ❏AmEx ❏Diners ❏I authorize Medco to charge this card for all orders from any person in this membership.
❏Rush this shipment ($15, subject to change). Note: This will not rush prescription processing.
(Street address required; P.O. box not allowed.)
Mailing instructions are provided on the next page
Patient/doctor Information continued
❏Spouse ❏Dependent ❏Domestic partner ❏Spouse ❏Dependent ❏Domestic partner Important reminders and other information
Check that your doctor has prescribed the
Medco at the number on your member ID card and maximum days' supply allowed by your plan, plus ask to speak with a pharmacist. Pharmacists are refills for up to 1 year, if appropriate (not a 30-day available 24 hours a day, 7 days a week, to answer questions concerning your prescription.
Complete a patient/doctor section for each person
❏ If you live in Texas, you have a right to refuse generic substitution. In many cases, choosing abrand-name product will result in a higher Be sure you have filled out the Health & Medication
co-payment. Check the box if you do not want a
less expensive, generic version of your
Unpaid balances
medication. Please note that this only applies to
If your plan limits the balance that you can carry on this prescription and future refills of this your account and you exceed that limit with this order, payment must be included. To price a If you have Medicare Part B coverage
medication, visit us online at www.medco.com and
Medco does not submit prescription drug claims to click "Price a medication." To avoid processing Medicare Part B. Check your Medicare Part B delays, call Member Services to enroll in our coverage to determine whether Medicare Part B e-check program or provide a credit card number in covers your prescription(s) and whether it will cost the "Complete your order" section on side 1.
you less to use a Medicare Part B participating Generic substitution
Texas, Florida and Ohio laws allow a generic participating pharmacies, call your local Medicare equivalent drug to be substituted for certain carrier or call 1 800 MEDICARE (1 800 633-4227).
brand-name drugs, unless you or your physician For questions about your Medco-administered specifically directs otherwise. Ask your doctor or coverage, please call Member Services.
pharmacist whether safe, effective and less If you need additional information or
expensive generic drugs are right for you. Or, call assistance, visit us online at www.medco.com or
call Medco Member Services.
Mailing instructions
Medco Health Solutions of
Fairfield
P.O. Box 747000
Cincinnati, OH 45274-7000
Do not use staples or paper
NMSFNP1W REV 12/07
X00000-00000-000-0000 12/07
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 prescription drug benefits with Medco
By Mail.

If you need additional forms you may copy this form or call your toll-free Member Services 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 benefit 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 only the name of the medication allergy in the bottom section of this chart.
Correct way to mark circles: •
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.
(NSAIDs) (e.g. ibuprofen, Advil®,Motrin®) If there is a drug allergy to report and not
listed above, please print only the name of
the drug in the space.
Example : Morphine —————————>
Please continue on next page to tell us about any medical conditions.
Medco is a registered trademark of Medco Health Solutions. Inc.
™ 2008 Medco Health Solutions, Inc. All rights reserved
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 particular family member has any of the
following conditions.
Spouse/SSDP
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)
(GERD)
Inflammatory bowel disease (colitis,
Crohn's disease)
High pressure in the eyes (glaucoma)
Poor circulation in legs (peripheral vascular hyperplasia, BPH)
Print other medical conditionsExample : 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 Medco Delivery form or refill order form.
Pay for medications with
e-check. It's easy, convenient,
and secure!
Medco now offers e-check to easily andconveniently pay for medications.
With e-check, one of the most securepayment methods available today, theco-payment or coinsurance is automaticallydeducted from your checking account. Andyou have a 10-day grace period between thetime we send the order and the day theamount is deducted from your checkingaccount.* To enroll and authorize Medco, just completethe form on the back and return it with yournext order! Authorization
I authorize Medco to initiate a debit entry to
the checking account provided on the back of
this form. This authorization permits Medco
to charge unpaid balances and future orders
made by all covered dependents to my
account, based on my authorization provided
by mail, phone, or web. On future orders,
Medco will include the amount to be charged
to my checking account with the order. I
acknowledge that the origination of ACH
transactions to the account must comply with
the provisions of U.S. law. This authorization
will remain in effect until I have canceled it.
*Please note that if there are insufficient funds at thetime Medco submits the funds transfer request, Medcowill charge a $10 fee. Your bank also may charge anonsufficient funds fee.

Source: http://usw351.org/sites/default/files/forms/mailorder_with_history.pdf

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