Payment is due with each order and may be made by credit card, check or money order. Orders received without payment
may delay processing. There is a $20 returned check charge.
Credit card information
To authorize payment by credit card, provide the account number, expiration date and signature. We accept Discover,
MasterCard, VISA and American Express. This card will be used for this and all future orders unless we are notied
Expiration DateCredit Card Number
Use credit card on le, with the last 4 digits of:
This is a change of address This is a one time address Seasonal address from to
Alternate Shipping Address (if different than permanent address)
Zip Code Phone NumberCity State
Shipping time does not include processing time. Shipping prices are subject to change.
We are unable to ship second business day or next business day orders to PO boxes.
Shipping address must be a physical location.
Regular: No charge Second business day: $15*
charged to you.
Next business day: $22*
Check Money Order
Check or money order
Please make check or money order payable to Prime Therapeutics and
include your member ID on the memo line. Do not send cash.
Pharmacy law may permit pharmacists to substitute a less expensive FDA-approved generically equivalent medication
for a brand-name medication unless you or your prescriber indicate otherwise. Some health plans require the patient to
pay the difference between generic and brand name cost.
By returning this form to PrimeMail, you consent to the release and use of the patient’s health information to the
patient’s health plans and health care providers/agents for health benets management. Prime Therapeutics’ use or
disclosure of individually identiable health information, whether furnished by you or obtained from other sources such
as medical providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability
and Accountability Act of 1996).
PrimeMail may contact your physician for clarication and safety purposes, which may result in your physician
prescribing a different, clinically appropriate product.
Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue
The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue
Cross and Blue Shield
Association. The Horizon® name and symbols are registered marks of Horizon Blue
Cross Blue Shield of New Jersey
PrimeMail is a registered trademark of Prime Therapeutics LLC.
© Prime Therapeutics LLC 05/13