Missiontexas.us

blue cross and blue shield of texas
mail order form — primemail® pharmacy
iNstructioNs: Please PrINT in CAPITAL letters using black ink only. Fill in the applicable ovals completely ( ).
For information about your pharmacy benefits, to preregister or to download additional order forms or a physician fax form, visit the Blue
Cross and Blue Shield of Texas Web site at www.bcbstx.com or call customer service at 877.299.2377 for HMO Blue® Texas members or
800.521.2227 for all other members.
member and Dependent history section information is required only on the first order unless there is a change in health status.
Indicate all known allergies, conditions or other current medications for you, your spouse, or your dependents by filling in the corresponding
oval that matches the description. Please detail * as necessary. Contact your physician if you are unsure about any of this information.
m e m b e r a N D D e p e N D e N t h i s t o r Y s e c t i o N
Any person who knowingly presents a false or fraudulent claim for the payment of a loss Member ID Number (on face of member ID card) Group Number is guilty of a crime and may be subject to fines a l l e r G i e s
c o N D i t i o N s
Member First Name MI Birth Date (MM/DD/YYYY) PCN (back of ID card) Member Phone Number * Please detail "other allergy " or "other condition," including related medications. ___________________________________________________ a l l e r G i e s
c o N D i t i o N s
* Please detail "other al ergy " or "other condition." a l l e r G i e s
c o N D i t i o N s
* Please detail "other allergy " or "other condition."__________________________ a l l e r G i e s
c o N D i t i o N s
* Please detail "other allergy " or "other condition."__________________________ • Do you want the Generic? ____ Yes (if available and your doctor permits) ____ No
• Some health plans require the patient to pay the difference between generic and brand name cost. State law allows pharmacist to substitute a less expensive generically equivalent drug for a brand drug unless you or your physician directs otherwise.
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blue cross and blue shield of texas mail order form — primemail® pharmacy
p r e s c r i p t i o N s e c t i o N — Please PrINT in CAPITAL letters using black ink only.
For NeW prescriptions you may use either:
For refill prescriptions you may use:
mail — Mail the original physician-signed prescriptions with this
phoNe — Call our automated refill line at 877.357.7463.
completed form to: blue cross and blue shield of texas
■ Web — Visit www.bcbstx.com
c/o primemail pharmacy, p.o. box 650041, Dallas, tX 75265-0041
■ mail — Mail this form with the refill information completed to:
■ faX — Your physician must fax both pages of this completed form,
blue cross and blue shield of texas
along with your prescription(s), to 877.774.6360 provided you have
c/o primemail pharmacy p.o. box 650041, Dallas, tX 75265-0041
either previously completed and submitted this form or registered
at www.bcbstx.com
physician Name/phone Number/Drug Name
prescription Numbers
patient Name
(for new prescriptions only)
(for refills only)
primemail pharmacy staff may contact your physician for clarification and safety purposes, which may result in your physician prescribing a
different, clinically-appropriate product. primemail pharmacy will dispense fDa-approved generic equivalents when available and appropriate.
paY m e N t s e c t i o N — Payment is due with each order and may be made by credit card, check or money order.
Do not send cash. Orders received without payment wil delay processing. Credit card is the only payment option for faxed orders. If you have questions
about your payment amount, cal the Prescription Drug Inquiry Unit at 877.299.2377 for hmo blue texas members or 800.521.2227 for all other members.
payment by check or money order (Make payable to Prime Therapeutics LLC and write your member ID number on the memo line.)
Check Amount: _______________________ Check Number: _______________________
payment by credit card (Provide information below) MasterCard Visa American Express Discover
use credit card on file, with the last four digits:
use alternate credit card number
Your credit card will be charged for drug costs, expedited shipping (if requested) use this card for all future orders
s h i p m e N t s e c t i o N — Delivery date does not include prescription processing time. Please choose your shipping method.
regular — no charge second business Day* Next business Day* *additional costs charged to you
If you’ve chosen Second Business Day or Next Business Day shipping, we are unable to ship to P.O. boxes. Shipping address must be a physical location.
ship to permanent address
spanish prescription labels
Alternate Shipping Address (If different than permanent address) above address is: for this order only for this and all future orders
all medications in this order will be sent to the address provided on this form. if a family member's medication needs to be delivered
to a separate address, please submit a separate order form.
by returning this form to primemail, you consent to the use and release of your health information and that of your covered dependents (if you are their
guardian or authorized representative) to your health plans and health care providers/agents for health benefits management. prime therapeutics’ use or
disclosure of individually identifiable health information, whether furnished by you or obtained from other sources such as medical providers, shall be in
accordance with the federal privacy regulations under hipaa (health insurance portability and accountability act of 1996).
† A division of Health Care Service Corporation, a Mutual Legal reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 4 0 6 9 0 - 1 0 0 5 P r I M E T H E r A P E U T I C S L L C pa G e 2 o f 2

Source: http://www.missiontexas.us/wp-content/uploads/2010/06/RX-Mail-Order-Form.pdf