Place your prescription(s), this form, and your
payment in an envelope. Do not use staples
or paper clips.
Patient/doctor information continued
Important reminders and other information
FOLD HERE
FOLD HERE
Express Scripts will make all possible efforts, as
appropriate by law, to substitute generic formulations
of medication, unless you or your doctor specifically
directs otherwise.
Pennsylvania and Texas laws permit pharmacists to
substitute a less expensive generic equivalent for a
brand-name drug unless you or your doctor directs otherwise.
Check the box if you do not wish a less expensive
brand or generic drug.
Please note that this applies only to new prescriptions and to
any refills of that prescription.
For additional information or help, visit us at
Express-Scripts.com or call Member Services at the phone
number found on your ID card. TTY/TDD users should call
1.800.759.1089.
Federal law prohibits the return of dispensed controlled
substances.
Check that your doctor has prescribed the maximum days’
supply allowed by your plan (not a 30-day supply), plus
refills for up to 1 year, if appropriate. Also, ask your doctor
or pharmacist about safe, effective, and less expensive
generic drugs.
Complete the Health, Allergy & Medication Questionnaire.
There may be a limit to the balance that you can carry
on your account. If this order takes you over the limit, you
must include payment. Avoid delays in processing by using
e-checks or a credit card. (See Section 3 for details.)
If you are a Medicare Part B beneficiary AND have
private health insurance, check your prescription drug
benefit materials to determine the best way to get
Medicare Part B drugs and supplies. Or, call Member
Services at the phone number found on your ID card. To
verify Medicare Part B prescription coverage, call
Medicare at 1.800.633.4227.
First name Last name
Doctor’s phone numberDoctor’s last name 1st initial
Patient’s relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent
MF
First name Last name
Doctor’s phone numberDoctor’s last name 1st initial
Patient’s relationship to memberBirth date (MM/DD/YYYY) Sex
Self Spouse Dependent
MF
MLRFOHNW
EXPRESS SCRIPTS
PO BOX 747000
CINCINNATI, OH 45274-7000
C
