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Writable Mail Order Form
INSTRUCTIONS FOR ORDERING YOUR MAINTENANCE/SPECIALTY MEDICATIONS
Welcome to the HealthTrans mail order service plan. The mail order service is designed for those patients who require medications on a recurring basis. Mail order is convenient for you, because the medications are mailed directly to your home.
Step 1 - Doctor Prescription
To begin using mail order, you must first obtain a written prescription from your doctor for a 90-day supply.
Typically, only certain drugs are available for a "maintenance" 90-day prescription. Please have your doctor verify if your particular medication is on the maintenance drug list. The original prescription must be submitted along with the completed mail order form.
Step 2 - Fill Out Form
Take a few minutes to complete the form on the back of this page. Please fill out the order form completely and print clearly. Use one order form for each Patient ordering medication(s). Missing information delays the processing of your order.
Step 3 - Select Payment Option
When using a credit card, be sure to include your credit card number and expiration date. HealthTrans Pharmacy cannot process or ship your order without payment in full. If you know the total payment due, you can also pay by personal check or money order, however these methods may delay processing.
HealthTrans Pharmacy provides free standard shipping for prescriptions. If you choose to have your medication shipment rush-ordered, additional costs will apply.
Step 4 - Submit form to HealthTrans
Send a copy of completed form and your original prescription(s) to:
P.O. Box 4057
Greenwood Village, CO 80155-4057
MEDICATION SUPPLY CONSIDERATIONS
Be sure to place your order at least 21 days before you run out of your current medication supply. Your benefit plan requires your doctor to write a prescription for a 90-day supply. If you need a prescription fulfilled immediately, ask your doctor to write a 30-day prescription that you can have filled at your local pharmacy, and a 90-day prescription for you to send to HealthTrans Pharmacy. (Please note: If your doctor specifies a quantity less than 90 days, it will be filled as written on the prescription. For example: if the prescription specifies a 30-day supply, HealthTrans Pharmacy will fill the prescription for 30 days.)
Pharmacy Regulations prohibit HealthTrans Pharmacy from honoring requests to cancel or return prescription orders after the order has been received.
HIPAA - This document is covered under the guidelines and federal law regarding patient privacy information.