Form Bwx514 - Medco By Mail Order Form
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1
2Medco By Mail Order Form
For All Mail Service Orders
For Refills
Place all prescriptions and refill slips together with this completed
To order on the Internet: Visit MyPharmacyPlus through the
order form and your copayment in the enclosed return envelope.
Pharmacy section at Have your Member ID
Be sure to fold the form as indicated so the address on the
number and Prescription (Rx) number on hand. Your 12-digit
bottom right shows through the window.
Prescription or Rx number can be found on your refill slip.
For New Prescriptions
To order by phone: Call 1-800-4REFILL (1-800-473-3455) to use
Fill out one line of the Patient Information Section for each new
the automated refill system. Have your Member ID number and
prescription you send. Be sure to include the patient's full name,
your refill slip with the prescription information ready.
date of birth, and address, along with the doctor's name and
To order by mail: Include your refill slip(s) with this form. Do
phone number. Your Mail Service cost share applies regardless
not complete the Patient Information section for refills.
of the days’ supply written on your prescription. To optimize
your benefit, prescriptions should be written for up to the
If You Need Additional Help
supply maximum allowed by your Plan.
Call Medco Member Services at 1-800-391-9701. They are
open 24 hours a day, 7 days a week. See the back of this form
for additional instructions.
Subscriber Information (See your ID card)
Identification Number
Prefix
Shipping address if different from your mailing address
Check if
Temporary
Permanent
Rx Group Number: BCWAPDP
Employer Group Name:
Subscriber Name: __________________________________________
Street Address: ____________________________________________
____________________________________________
City, ST, ZIP: ______________________________________________
________________________________________
Daytime telephone
Evening telephone
________________________________________
Patient Information
—c
omplete one line for each new prescription (Do not complete for refills)
Does patient
Patient name and Medicare B
Patient’s relation to Plan
Birth date
Doctor name
have any other
number (if applicable)
Subscriber (fill in one)
Gender
M/D/YYYY
and phone number
prescription plan?
1
Self
Spouse/Domestic Partner
Dependent
M
Yes
/
/
F
No
2
Self
Spouse/Domestic Partner
Dependent
M
Yes
/
/
F
No
3
Self
Spouse/Domestic Partner
Dependent
M
Yes
/
/
F
No
Order Information
Paying by Credit Card?
Visa
MC
Disc/NOVUS
AmEx
Diners
Total number of medications in this order
(including all refills and new medications)
CREDIT CARD NUMBER
X
M
Y
Subtotal of this order
$
.
EXPIRATION DATE
CARDHOLDER SIGNATURE
Optional expedited shipping
.
Check here to have all orders billed to your credit card.
$14.00 (subject to change)
By doing so, you authorize Medco to keep your card
Total enclosed
number on file and bill all future orders directly to your credit
$
.
(do not send cash)
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 Health Solutions, Inc.
MEDCO HEALTH SOLUTIONS OF FORT WORTH
P O BOX 650022
DALLAS TX 75265-0022
!7526500221!
FORM #BWX514 (07-2007)
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