Form He58918 - Highmark Blue Shield Medco By Mail Order Form (Page 2 of 2) in pdf

For Refills

For New Prescriptions

To order online:

Fill out one line of the Patient Information

Have your member ID number and prescription

section for each new prescription you send. Be

(Rx) number on hand. Your 12-digit prescription or

sure to include the patient’s full name, date of

Rx number can be found on your refill slip.

birth, and address, along with the doctor’s

name and phone number.

To order by phone: Call 1 800 4REFILL

(1 800 473-3455) to use the automated refill

For All Medco By Mail Orders

system. Have your member ID number and your

Place all prescriptions and refill slips together

refill slip with the prescription information ready.

with this completed order form and your

co-payment in the enclosed return envelope.

To order by mail: Include your refill slip(s) with this

Be sure to fold the form as indicated so the

form. Do not complete the Patient Information

address on the bottom right shows through the

section for refills.

window.

If You Need Additional Help

Call Member Services at 1 800 903-6228. Best

times to call are Tuesday through Friday

afternoons.

Please take a minute to make sure…

Additional Instructions

If you elect to have this and all future orders

• You have included your doctor’s signed

automatically charged to your credit card by

prescription form and filled out the

checking the box on the front or enrolling

patient information on the front of the

by phone, bear in mind that the automated

order form for each new prescription.

payment plan feature will apply to all

• You have either filled out the credit card

Medco By Mail orders. Also note that we

section on the front of this order form or

can only keep one credit card on record.

included a check or money order for the

You may have a balance limit on your plan

required co-payment.

account. If you do, once your unpaid balance

• You have written your member ID

exceeds that limit, no additional orders will be

number on any check or money order.

processed until the balance is paid.

• The Medco address on the front shows

You can call 1 800 948-8779 anytime to

through the window of the return envelope.

enroll in our automated payment plan,

change the credit card on file, check your

• You have filled out the Health, Allergy

and Medication Questionnaire. This

account balance, or pay by phone using a

information will help Medco better serve

credit card.

your prescription drug needs.

Get more information online

Expedited shipping available

Visit us at

For an additional fee, your order will be

shipped by an expedited service offered to

your area. This option must be chosen when

you make the order and cannot be applied

after an order is already processed.

FORM #HELG2535

(08/08)

FORM #HE58918

Form He58918 - Highmark Blue Shield Medco By Mail Order Form Page 2

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