Fillable Home Delivery Order Options (New Mexico Public School Insurance Authority)

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Home Delivery Order Options (New Mexico Public School Insurance Authority)

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Patient Last Name
Patient First Name
Home Delivery Order Options
Ask your doctor to write your prescription for up to a 90-day supply or the maximum days allowed by your plan
with refills up to one year, if appropriate.
ePrescribe: For fastest service ask your doctor to submit prescriptions electronically to the Express Scripts Pharmacy
SM
.
Online/Mobile App: Log in to express-scripts.com or the Express Scripts Mobile App, choose the medicine you want
delivered, add it to your cart, then check out.
Fax: Have your doctor call 888.327.9791 for faxing instructions. (Faxes can only be accepted from a doctor’s office.)
Phone: Call Express Scripts at the toll-free number on the back of your ID card for assistance in switching to home delivery.
Mail: Complete the order form and send to Express Scripts along with prescriptions and payment.
Please use ALL CAPITAL LETTERS with black or blue ink. Fill in the ovals as shown. ( )
1
Member Information
Member ID Number
Group #
Member Last Name
Member First Name
Please send email notices regarding this order’s status
Email address
To GO GREEN go to express-scripts.com to update your Communication Preferences under Account
2
Shipping Address
Permanent Temporary
If temporary address, please provide effective dates
From
____/____/____ To ____/___/_____
Shipping Address Line 1
(Street address is preferred over PO Box)
Apt#
Shipping Address Line 2
City
State
Zip
Choose One
M
W
H
Primary Phone Number Secondary Phone Number
Choose One
M
H
W
Shipping Method
(Expedited shipping will not rush prescription processing)
Standard
Free
Arrives within 5-10 days after order is shipped
Two Day
$12.00
Arrives 2 business days after order is shipped
One Day
$21.00
Arrives 1 business day after order is shipped
3
Patient Information
Please only include prescriptions for patients covered under the above Member ID
Patient #1
Patient Last Name Patient First Name
Patient DOB
Gender Male Female
Physician Name
Physician Phone
Patient #2
Patient Last Name
Patient First Name
Patient DOB
Gender Male Female
Physician Name
Physician Phone
©2018 Express Scripts. All Rights Reserved EME47693 CRP1808_0413 STLNESEW
4 Payment Method
Do not send cash
You authorize us to retain on file your payment card details that you used to make this purchase and to charge your payment card
account to pay for any prescription orders requested by you. Should you also choose to enroll in the auto-pay program, you further
consent that we may charge your enrolled payment method for prescription orders made by covered household members, including
previously ordered prescriptions which are unpaid.
• We will notify you of any changes to this authorization by email or mail as applicable. This Card on File Authorization, and if
applicable auto-
pay enrollment, will remain in effect until you cancel the authorization by logging into your account or calling the
1-800 number on the back of your prescription card. The transaction amount is determined by your plan’s benefit structure at
the time the prescription is shipped.
• State law prohibits the return of prescription medications for resale or reuse. We cannot accept the return of properly dispensed
prescription medications for credit or refund.
• See our privacy policy for information regarding our use and disclosure of personally identifiable information.
Signature X ____________________________________________________________
Credit Card:
We accept VISA, MC, Discover, AMEX, Diners
Automatic, ongoing payment through credit card
Authorize to pay for this order and all future orders with the
credit card below.
For this order only. Simply fill
in your credit card
information below.
Credit Card Number
________________________
_________________
______________
Exp Date
Check or Checking Account
________________________
____________________
Automatic, ongoing payment through checking account
I authorize to
pay for this order and all future orders with the checking
account information below or include a voided check.
For this order only. Enclose a check payable to Express Scripts.
Write invoice number on the check.
Name of checking account holder
Checking Account
Number
__________________
__________________________
Routing Number (first 9 digits
lower-left corner of personal
check)
____________________________________________
Review your account balance and pay outstanding balances anytime at express-scripts.com. To change the limit of the amount we
can charge your card without a call to you:
• Go to express-scripts.com
• Select Payment Methods under Account then Edit Information.
• Change the payment authorization limit
You can manage all account preferences at express-scripts.com or call Member Services at the toll-free number on your ID card.
5 Health History
To update your allergies or health conditions: Visit us at express-scripts.com/healthform or call 877.438.4417. This information
helps us protect you against potentially harmful drug interactions and allergies.
6 Important reminders and other information
If you are a Medicare Part B beneficiary AND have private health insurance, check your prescription drug benefit materials to
determine the best way to get Medicare Part B drugs and supplies. Or, call Member Services at the toll-free number found on your
ID card. To verify Medicare Part B prescription coverage, call Medicare at 1.800.633.4227.
For additional information or help, visit us at express-scripts.com or call Member Services at the toll-free number found on your ID
card. TTY/TDD users should call 1.800.759.1089.
Your order may be filled at any one of our Express Scripts Pharmacies located nationwide.
7 Generic Substitution
State law permits a pharmacist to substitute a less expensive generic equivalent drug for a brand-name drug unless you or your
physician directs otherwise. Please note that this applies to new prescriptions and to any future refills of that prescription. Also be
aware that you may pay more for a brand-name drug.
I do not wish to receive a less expensive brand or generic medication.
If the prescription is being submitted electronically, discuss with your doctor.
Place your prescription(s), order form(s)
and your payment in an envelope.
Do not use staples or paper clips.
Do not affix post it notes to form.
EXPRESS SCRIPTS
PO BOX 66564
ST LOUIS, MO 63166-6564
EME47693 CRP1808_0413 STLNESEW
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Home Delivery Order Options (New Mexico Public School Insurance Authority)

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Completed 7 January 2021

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