Fillable Home Delivery Order Options (University of Texas System)

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Home Delivery Order Options (University of Texas System)

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Home Delivery Order Options
Ask your doctor to write your prescription for up to a 90-day supply or the maximum days allowed by your plan
with refills up to one year, if appropriate.
ePrescribe: For fastest service ask your doctor to submit prescriptions electronically to the Express Scripts Pharmacy
SM
.
Online/Mobile App:
Log in
to
express-scripts.com
or the Express Scripts
Mobile App, choose the medicine you want
delivered, add it to your cart, then
check out.
Fax: Have your
doctor call 888.327.9791 for faxing instructions.
(Faxes can
only
be accepted from a doctor’s office.)
Phone:
Call Express Scripts at the toll-free number on
the back of your
ID
card for assistance
in switching to
home delivery.
Mail:
Complete the order form and send
to
Express Scripts along with prescriptions and payment.
Please use ALL CAPITAL LETTERS with black or blue ink. Fill in the circle as shown. ( )
1 Member Information
Patient Last Name
Patient First Name
Member ID Number
Group #
Member Last Name
Member First Name
Please send email notices regarding this order’s status
Email address
To GO GREEN go to express-scripts.com to update your Communication Preferences under Account
2
Shipping Address
Permanent
Temporary
If temporary address, please provide effective
dates From____________ To ____________
Shipping Address Line 1
(Street address is preferred over PO Box)
Apt#
Shipping Address Line 2
City
State
Zip
Circle One
Primary Phone Number
___________________________
Mobile Home Work
Secondary Phone Number
__________________________
Mobile Home Work
Shipping Method (Expedited shipping will not rush prescription processing)
Standard Free Arrives within 5-10 days
after order is shipped
Two Day $12.00 A
rrives 2 business days after order is shipped
One Day $21.00 Arrives 1 business day after order is shipped
3
Patient Information
Please only include prescriptions for patients covered under the above Member ID
Patient #1
Patient Last Name Patient First Name
Patient DOB
Gender Male Female
Physician Name
Physician Phone ________________________
Patient #2
Patient Last Name
Patient First Name
Patient DOB
Gender Male Female
Physician Name
Physician Phone ________________________
©2018 Express Scripts. All Rights Reserved EME47693 CRP1808_0413 STLF14WB
4
Payment Method
Do not send cash
Interested in easy, automatic, ongoing payments? You must SIGN here to enroll. The payment information you provide will be
used for all prescription orders made by covered household members, including previously ordered prescriptions not yet filled. All
personally identifiable information collected on this site is protected and secure. The payment information that you provide to us is
securely maintained in our files for your convenience.
Signature X ____________________________________________________________
Credit Card: We accept VISA, MC, Discover, AMEX, Diners
Automatic, ongoing payment through credit card
Authorize to pay for this
order and all future orders
with
the credit card below.
For this order only.
Simply fill in your credit card
information below.
Credit Card Number
Exp Date
(MM/YY)
Check or Checking Account
_________________________________________
______________
____________________________________________
Automatic, ongoing payment through checking account
I authorize to pay for this order and all future orders with the
checking account information below or include a voided check.
For this order only. Enclose a check payable to Express
Scripts. Write invoice number on the check.
Name of checking account holder
Checking Account Number
____________________________________________
Routing Number (first 9 digits lower-left corner of personal check)
____________________________________________
Review your account balance and pay outstanding balances anytime at express-scripts.com.
To change the limit of the amount we can charge your card without a call to you:
• Go to express-scripts.com
• Select Payment Methods under Account then Edit Information.
• Change the payment authorization limit
You can manage all account preferences at express-scripts.com or call Member Services at the toll-free number on your
ID card.
5
Health History
To update your allergies or health conditions: Visit us at express-scripts.com/healthform or call 877.438.4417. This
information helps us protect you against potentially harmful drug interactions and allergies.
6
Important reminders and other information
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 toll-free
number found on your ID card. To verify Medicare Part B prescription coverage, call Medicare at 1.800.633.4227.
Medication return policy: State law prohibits the return of prescription medications for resale or reuse. Express Scripts
cannot accept the return of properly dispensed prescription medications for credit or refund.
For additional information or help, visit us at express-scripts.com or call Member Services at the toll-free number found
on your ID card. TTY/TDD users should call 1.800.759.1089.
Your order may be filled at any one of our Express Scripts Pharmacies located nationwide.
7
Generic Substitution
State law permits a pharmacist to substitute a less expensive generic equivalent drug for a brand-name drug unless you
or your physician directs otherwise.
Please note that this applies to new prescriptions and to any future refills of
that prescription. Also be aware that you may pay more for a brand-name drug.
I do not wish to receive a less expensive brand or generic medication.
If the prescription is being submitted electronically, discuss with your doctor.
Place your prescription(s), order form(s)
and your payment in an envelope.
Do not use staples or paper clips.
Do not affix post it notes to form.
EXPRESS SCRIPTS
PO BOX 66577
ST LOUIS, MO 63166-6577
EME47693 CRP1808_0413 STLF14WB
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Home Delivery Order Options (University of Texas System)

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Completed 13 January 2021

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