Mail Service Pharmacy Tips Walgreens Mail Service Illinois Comprehensive Health
• Complete attached registration form. You may also
register yourself (and dependents, if applicable) at
Insurance Plan REGISTRATION & PRESCRIPTION ORDER FORM
• New prescriptions must be mailed to the mail
Use black ink only. Enclose form with prescription(s) and payment.
PARTICIPANT INFO.
Suffix extension Patient needs snap-on caps
• For long-term medications you need right away: ask
your doctor for two prescriptions—one for a small
supply to fill at a participating retail pharmacy, and
one for a long-term supply to fill through the mail.
• If two or more prescriptions are sent in for multiple
family members, the prescriptions will be shipped,
as a single order, to an adult family member at the
Shipping Address (Please do not use P.O. Box)
address given on the order form. If you prefer
different shipping arrangements for privacy or other
reasons, please contact our Customer Care Center.
• Most orders are shipped by U.S. Postal Service.
Controlled substances may require an adult
signature upon receipt. Packaging does not show
ALLERGIES:
any indication that medications are enclosed.
HEALTH CONDITIONS:
• Emergency prescriptions can be shipped overnight.
• Include payment, if applicable to avoid any delays.
PAYMENT – CHECK OR CREDIT CARD (VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS)
It is standard pharmacy practice to substitute Rx Type
• Make checks payable to Walgreens Mail Service.
generic equivalents for brand-name drugs
whenever possible. Walgreens Mail Service will
• Refills cannot be transferred from other
dispense an FDA-approved generic equivalent
pharmacies. Request a new prescription from your
whenever available, permitted by your prescriber,
and allowable by law. If you do not want a
Customer Care Center:
generic equivalent, please call our Customer
1-888-265-1807 (TTY: 1-800-573-1833)
Monday–Friday, 8:00 a.m. – 10:00 p.m. (Eastern)
Saturday–Sunday, 8:00 a.m. – 5:00 p.m. (Eastern)
Refills by Phone: Internet:
Mail to: Walgreens Mail Service P.O. Box 29061, Phoenix, AZ 85038-9061
Turn page and complete dependent info. on the other side of this form. DEPENDENT INFO. Suffix
Shipping Address (if different than participant)
ALLERGIES: HEALTH CONDITIONS: DEPENDENT INFO. Suffix
Shipping Address (if different than participant)
ALLERGIES: HEALTH CONDITIONS: Please Note: By submitting this form, you have authorized Customer Care Center:
release of all information to Walgreens Mail Service (and
other necessary parties) as required to process your prescriptions and their refills under your benefit plan.
Monday-Friday, 8 a.m. – 10 p.m. (Eastern)
Saturday-Sunday, 8 a.m. – 5 p.m. (Eastern)
Medical Co-Payments Pursuant to IC 11-12-5-5 and Monroe County Ordinance 2002-35, the following changes apply to medical co-payment at the Monroe County Correctional Center. These provisions apply to medical co-payments by a jail inmate. The term jail inmate includes and applies to a person confined to the Monroe County Correctional Center except that it shall not include or apply to any inma
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DEPENDENT INFO. Suffix