Fillable Specialty Medication Order Form For Service Benet Plan

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Specialty Medication Order Form For Service Benet Plan

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The Specialty Medication Order Form For Service Benet Plan form is 2 pages long and contains:

  • 1 signature
  • 1 check-box
  • 120 other fields

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File type: PDF

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Specialty Medication
Order Form
Enter ID # below if not shown or if different
from above
Blue Cross and Blue Shield Federal Employee Program
Plan Sponsor or Company Name Prescription
Mail this form to:
BCBS FEP SDP, CVS Specialty
9310 Southpark Center Loop
Orlando, FL 32819
Please use blue or black ink, CAPITAL LETTERS and ll in both sides of this form.
New prescriptions
– Mail your new prescriptions with this form. Number of New prescriptions:
Refills – Order online, by phone or write in Rx number(s) below. Number of Refill prescriptions:
For fastest service, order refills toll-free at 1-888-346-3731.
A Shipping Address. To ship to an address different from the one printed above, please make changes here.
Last name First name MI Sufx (Jr, Sr)
Street address Apt/Suite #
Use this address
for this order only.
City State ZIP Code
-
Daytime phone # Evening phone #
- - - -
B Refills. To order refills by mail, enter your prescription number(s) here.
1)
2) 3) 4)
5) 6) 7) 8)
On behalf of the Blue Cross and Blue Shield Service Benefit Plan, CVS Specialty administers the Specialty
Pharmacy Program. CVS Specialty is an independent company that provides specialty drugs to Service
Benefit Plan members.
We may package all of these prescriptions together unless you tell us not to.
For Service Benet Plan Members
©2022 6500-SPECIALTY_FEP_SDP. All rights reserved.
C Tell us about the people getting prescriptions. If there are more than two people, please complete another form.
1st person
with a refill or new prescription. This person needs: Spanish forms and labels
Last name First name MI Sufx (Jr, Sr)
Nickname Date of birth (MM-DD-YYYY)
Gender: M F
- -
Email Date new prescription was written
Doctor’s last name Doctor’s first name Doctor’s phone #
Tell us about new allergies or health information for this person. Only tell us new information.
Allergies:
None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin
Sulfa Other:
Health information: Arthritis Asthma Diabetes Acid reflux Glaucoma Heart problems
High blood pressure High cholesterol Migraine Osteoporosis Prostate issues Thyroid
Other:
2nd person with a refill or new prescription. This person needs: Spanish forms and labels
Last name First name MI Sufx (Jr, Sr)
Nickname Date of birth (MM-DD-YYYY)
Gender: M F
- -
Email Date new prescription was written
Doctor’s last name Doctor’s first name Doctor’s phone #
Tell us about new allergies or health information for this person. Only tell us new information.
Allergies:
None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin
Sulfa Other:
Health information: Arthritis Asthma Diabetes Acid reflux Glaucoma Heart problems
High blood pressure High cholesterol Migraine Osteoporosis Prostate issues Thyroid
Other:
D Special instructions:
E How would you like to pay for this order? Fill in the oval to choose a payment method.
Electronic check. Pay from your bank account. Call Customer Care at 1-888-346-3731.
Credit or debit card. (Visa
®
, MasterCard
®
, Discover
®
, or American Express
®
)
Fill in this oval to use your card on file.
Fill in this oval to use a new card or to update your card expiration date.
Account # Exp. Date (MMYY) Cardholder signature/date
Fill in this oval if you DO NOT want to use this payment method for future orders.
6500-SPECIALTY_FEP_SDP
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Specialty Medication Order Form For Service Benet Plan

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Completed 19 January 2022

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