Place your prescription(s), this form, and your
payment in the envelope provided. Do not use
staples or paper clips.
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
M F
Patient/doctor information continued
First name Last name
Doctor’s phone numberDoctor’s last name 1st initial
Patient’s relationship to memberBirth date (MM/DD/YYYY) Sex
M F
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, log in to Express-Scripts.com
or call Member Services at 1-800-778-0735. 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.)
Please take a minute to make sure that you have either
filled out the credit card section on the front of this order
form or included a check or money order for the required
co-payment. If you elect to have this and all future orders
automatically charged to your credit card, bear in mind that
the automated payment plan feature will apply to all mail
orders.
Self Spouse Dependent
ID No: <<XXXXXXXXXXXX>>
Group No: <<XXX>>
*XXX*
*XXXXXXXXXXXX*
HH8677B
*123456789*
Program: <<XXXXXXXXX>>
EXPRESS SCRIPTS
PO BOX 6500
CINCINNATI, OH 45273-8152
C
