Gwl_webmailer

INSTRUCTIONS FOR PLACING YOUR ORDER
Contact your physician to write a new prescription for a three-month supply with authorized OPTION 1: MAIL Your Order
1. Complete the New Patient Home Delivery Form enclosed.
2. Attach your prescriptions to the order form.
3. Mail the New Patient Mail Home Delivery Form and your prescriptions to: Express Scripts, Inc.
Mail Pharmacy Service
PO Box 52111
Phoenix, AZ 85072-2111
GREAT-WEST
OPTION 2: Have your physician FAX Your Order
1. Complete the New Patient Mail Home Delivery Form enclosed.
2. Ask your physician to fax the New Patient Home Delivery Form and Fax Number: 1-800-297-2653
Legally, we can only accept a faxed prescription from your PHYSICIAN’S OFFICE.
Faxes sent from other locations (such as your home or workplace) will not be accepted.
PHYSICIAN NOTE: CII prescriptions cannot be faxed. All prescriptions for these
medications must be mailed.
NEW PATIENT HOME DELIVERY FORM
PLEASE PRINT IN ALL CAPITAL LETTERS USING BLACK INK.
IF THERE ARE MORE THAN 3 FAMILY MEMBERS, WRITE THE INFORMATION ON A SEPARATE PIECE OF PAPER.
1. PERSONAL INFORMATION
CARDHOLDER (REFER TO YOUR PLAN CARD)
ID NUMBER
FIRST NAME
LAST NAME
DRUG ALLERGIES (CHECK ALL THAT APPLY) PENICILLIN (01)
PLEASE PROVIDE A STREET ADDRESS. CERTAIN MEDICATIONS CANNOT BE DELIVERED TO A POST OFFICE BOX.
GREAT-WEST
PHYSICIAN LAST NAME
PHYSICIAN PHONE #
FAMILY MEMBER 1
FIRST NAME
LAST NAME
DRUG ALLERGIES (CHECK ALL THAT APPLY) PENICILLIN (01)
PHYSICIAN LAST NAME
PHYSICIAN PHONE #
FAMILY MEMBER 2
FIRST NAME
LAST NAME
DRUG ALLERGIES (CHECK ALL THAT APPLY) PENICILLIN (01)
PHYSICIAN LAST NAME
PHYSICIAN PHONE #
NEW PATIENT HOME DELIVERY FORM
FAMILY MEMBER 3
FIRST NAME
LAST NAME
DRUG ALLERGIES (CHECK ALL THAT APPLY) PENICILLIN (01)
PHYSICIAN LAST NAME
PHYSICIAN PHONE #
2. PAYMENT METHOD
PLEASE INCLUDE PAYMENT WITH YOUR ORDER. DO NOT SEND CASH. STANDARD DELIVERY OF YOUR ORDER IS FREE AND
SHOULD ARRIVE WITHIN 14 DAYS FROM THE DATE WE RECEIVE YOUR ORDER.
NOTE: YOUR CREDIT CARD WILL BE CHARGED ACCORDING TO YOUR PRESCRIPTION PLAN. ALL FUTURE ORDERS WILL BE CHARGED TO THIS CREDIT CARD, UNLESS PAYMENT (CHECK OR MONEY ORDER) ACCOMPANIES THE ORDER.
CHECK CARD
CREDIT CARD
CARDHOLDER
EXPIRATION DATE
GREAT-WEST
PLEASE PRINT NAME AS IT APPEARS ON CREDIT CARD NOTE: IF PAYING BY CHECK OR MONEY ORDER, PLEASE REFER TO YOUR PRESCRIPTION PLAN MATERIALS FOR PRESCRIPTION COPAY.
CHECK/MONEY ORDER
AMOUNT ENCLOSED $
3. SIGNATURE REQUIRED
PLEASE CHECK ANY OF THE TWO OPTIONS (IF APPLICABLE) AND SIGN THE FOLLOWING STATEMENT.
I WOULD LIKE MY PRESCRIPTIONS DISPENSED WITH I REQUEST THAT THIS AND FUTURE ORDERS BE SHIPPED NON-CHILD RESISTANT (EASY OPEN) CAPS.
“SIGNATURE REQUIRED” FOR AN ADDITIONAL CHARGE.
I CERTIFY THAT ALL THE INFORMATION ON THIS FORM IS CORRECT, INCLUDING ANY SELECTIONS MADE FOR SENDING MY ORDER SIGNATURE
REQUIRED OR FOR NON-CHILD RESISTANT (EASY OPEN) CAPS. I PERMIT EXPRESS SCRIPTS, INC. TO RELEASE ALL INFORMATION ON THIS FORM
CONCERNING PRESCRIPTION ORDERS TO MY PLAN SPONSOR, ADMINISTRATOR OR
HEALTH PLAN FOR THE PURPOSE OF PAYMENT, TREATMENT, OR HEALTH CARE OPERATIONS.
4. REMINDER
PRESCRIPTIONS THAT DO NOT INCLUDE THE INFORMATION BELOW MAY BE DELAYED OR RETURNED TO YOU UNFILLED.
PHYSICIAN INFORMATION: NAME • SIGNATURE • DEA NUMBER. IF THERE ARE MULTIPLE PHYSICIANS, CIRCLE YOUR
PATIENT INFORMATION: FIRST AND LAST NAME • ADDRESS • DATE OF BIRTH • ID NUMBER.
PRESCRIPTION INFORMATION: DATE WRITTEN • DRUG NAME • STRENGTH • MEDICATION DIRECTIONS • QUANTITY
QUESTIONS ABOUT YOUR PHARMACY BENEFIT?
CALL THE CUSTOMER SERVICE NUMBER THAT WAS PROVIDED TO YOU.

Source: http://www.bvsd.org/benefits/Documents/G-W%20Mail%20Order%20Form.pdf