100_4213_104

Medco Health Home Delivery
Pharmacy ServiceTM Order Form
Benefits Provided by UnitedHealthcare
For Refills
date of birth, and address, along with the doctor’s name and To order from our Web site: www.myuhc.com. Have your Customer
phone number. Be sure your prescription is written for a 90-day ID number and Prescription (Rx) number on hand. Your 12-digit Prescription or Rx number can be found on your refill slip.
For All Home Delivery Orders
To order by phone: Call 1 800 4REFILL (1 800 473-3455) to use the
Place all prescriptions and refill slips together with this automated refill system. Have your Customer ID number and your completed order form and your co-payment in the enclosed refill slip with the prescription information ready.
return envelope. Be sure to fold the form as indicated so theaddress on the bottom right shows through the window. To order by mail: Include your refill slip(s) with this form. Do notcomplete the Patient Information section for refills.
If You Need Additional Help
Call Customer Service at 1 800 948-8779. Best times to call
For New Prescriptions
are Tuesday through Friday afternoons.
Fill out one line of the Patient Information Section for each new prescription you send. Be sure to include the patient’s full name, See the back of this form for additional instructions.
Customer Information
Customer ID:
Shipping address if different from your mailing address
Group:
UHEALTH
Name:Street Address:Street Address:Street Address:City, ST, ZIP: You authorize release of all information to the plan administrator, underwriter, sponsor, policyholder, employer, and their agents foruse in connection with the benefit plan programs. Information may also be used for other reporting and analysis purposes withoutidentification of you or your family members.
Patient Information—complete one line for each new prescription (Do not complete for refills)
Order Information
Paying by Credit Card?
Total number of medications in this order
(including all refills and new medications)
Subtotal of this order
Optional expedited shipping
Check here to have all orders billed to your credit card.
By doing so, you authorize Medco Health to keep your card Total enclosed
number on file and bill all future orders directly to your credit card. To enroll by phone, please call 1 800 948-8779.
Paying by check? Write your Customer ID on your check or
money order made payable to Medco Health.
You can check your home delivery co-payments online at www.myuhc.com.
Ask your physician to write your prescription for a 90-day supply with
refills when appropriate. You will be charged a home delivery co-payment
ATTN: XXXXXXXXX
regardless of the days supply written on the prescription. Please be sure MEDCO HEALTH
that your physician writes your prescription for a 90-day supply, not a P O BOX 747000
CINCINNATI OH 45274-7000
100-4213 1/04
Please take a minute to make sure…
Additional Instructions
If you elect to have this and all future orders automatically • You have included your doctor’s signed prescription
charged to your credit card by checking the box on the front form and filled out the patient information on the
or enrolling by phone, bear in mind that the automated front of the order form for each new prescription.
payment plan feature will apply to all Home Delivery • You have either filled out the credit card section on
Pharmacy Service orders. Also note that we can only keep the front of this order form or included a check or
money order for the required co-payment.
You may have a balance limit on your plan account. If you • You have written your Customer ID on any check or
do, once your unpaid balance exceeds that limit, no money order.
additional orders will be processed until the balance is paid.
• The Medco Health address on the front shows through
You can call 1 800 948-8779 anytime to enroll in our the window of the return envelope.
automated payment plan, change the credit card on file,check your account balance, or pay by phone using a • You have filled out the Health, Allergy, and Medication
Questionnaire. This information will help
Medco Health better serve your prescription drug
Ohio Law allows a less expensive, generically equivalent drug to be substituted for certain brand-name drugs unless you oryour physician direct otherwise.
• Your medication will be delivered to you within 7 to
11 days after you mail your order.
Get more information from our Web site
• Your prescription is written for a 90-day supply with
refills.
Visit us at www.myuhc.com.
Expedited shipping available
For an additional fee, your order will be shipped by anexpedited service offered to your area. This option must bechosen when you make the order, and cannot be appliedafter an order is already processed.
Health, Allergy & Medication Questionnaire
Your answers to the following questions will help us provide your pharmacy benefit services including, for example, filling prescriptions and alerting your doctor about possible medication problems. To best serve you, we need to know if you have any known allergies, conditions ordiseases.
• Please complete the questionnaire for each family member enrolled in your pharmacy benefit plan.
• If you need additional forms you may call your customer service representative at the toll- • Return this questionnaire with your prescription or refill order form.
SECTION 1
SUBSCRIBER IDENTIFICATION AND CONTACT
Group Number
Subscriber Number
Daytime Telephone Number
Primary Subscriber: First Name M.I.
Last Name
Street Address/Apt. No.
SECTION 2
DRUG ALLERGY CONDITIONS
For each family member enrolled in the program, include his/her name, date of birth and gender.
For each family member fill in the circle ONLY if an allergy or bad reaction happened anytime
in the past. If you are allergic to a medication that is not listed, please print the name of the
medication allergy in the bottom section of this chart.
Correct way to mark circles:
Enrollee
Dependent Dependent Dependent
Penicillins/cephalosporins(e.g. ampicillin, Keflex®)Tetracycline antibioticsErythromycin, Biaxin®, Zithromax®Codeine (e.g. Tylenol #3®)Non-steroidal anti-inflammatorydrugs (NSAIDs) (e.g. ibuprofen)Aspirin (Salicylates)Sulfa drugsIodinePrint other medication allergiesnot listed above in the spaceprovided. Example: morphine Continue on the other side to tell
us about any medical conditions.
SECTION 3
MEDICAL CONDITIONS
Please list in the appropriate column the names of each family member enrolled. Then, for eachfamily member, fill in the circle next to each condition if a doctor ever said that particular familymember has the condition.
Enrollee
Dependent Dependent Dependent
Congestive heart failureHigh blood pressure Heart attack or anginaHigh cholesterolStroke Chronic bronchitis or emphysemaAsthmaAllergies, runny nose, hay feverHigh blood sugar (diabetes)Thyroid diseasePeptic, stomach, or duodenal ulcerGastric reflux, heartburn, oresophagitis (GERD)Inflammatory bowel disease(colitis, Crohn’s disease)High pressure in the eyes(glaucoma)SeizuresPoor circulation in the legsTrouble with blood not clottingproperlyEnlarged prostate(benign prostatic hyperplasia,BPH)ArthritisOsteoporosisDepressionMigraine headachePrint other medical conditionsnot listed above in the spaceprovided. Example: glaucoma Please return the questionnaire with your prescription or refill order form.
Thank You

Source: http://www8.georgetown.edu/benefits/gushare.georgetown.edu/UniversityBenefits/web/Forms/UHC_Medco_PharmClaim.pdf