Important benefit information
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1 Important Important Important Please keep for records Important Please keep for records Please keep for records Please keep for records Welcome to Express Scripts! Welcome Welcome to to Express Express Scripts! Scripts! We re manager of for Welcome toof Express Scripts! Blue Cross Blue Shield West Virginia. We ll We re manager for We re of Blue for manager quickly get need. Blue Cross Shield Westdrugs Virginia. We ll Blue Cross Blue Shield West Virginia. We ll getof drugs need. We re quickly manager for quickly get drugs need. Blue Cross Blue Shield West Virginia. We ll You can use ID when send in quickly get drugs need. a new or visit our website for You can use ID when send in You can use ID when send in first time. a new or visit our website for a new or visit our website Youfirst cantime. use ID when sendfor in first time. a new or visit our website for a question about a? Call us! Our Have first time. areabout available 24/7 to Call us! out. No matter Have a question a? Our how s phone, Have a question about a? Call out. us! Our are available 24/7 to Noby matter mail, we ll work with out. doctors to available 24/7 to s how are No bymatter phone, Have a online question about a? Call us! Our safeguard health. how are s byto phone, mail, online we ll work with available 24/7 to doctors out. No matter mail, online we ll work with doctors to safeguard health. how s by phone, safeguard health. mail, online we ll work with doctors to safeguard health. Please see or side for more about with free stard shipping. Please see or side for more about with free stard shipping. Please see or side for more about with free stard shipping. Please see or side for more about with free stard shipping. See copayments or important online: or important See copayments See copayments or important online:to save Choose opportunities money. online: See copayments or important Easily renew s. Choose opportunities to save money. online: Choose opportunitieshealth to save money. Receive safety alerts. Easily automatic renew s. renewto s. Easily Choose opportunities save money. Contact a pharmacist. Receive automatic health safety alerts. Receive automatic health safety alerts.s. Easily renew LTR239401A 09/2014 Contact a pharmacist. pharmacist. Contact Receive aautomatic health safety alerts. LTR239401A 09/2014 LTR239401A 09/2014 Contact a pharmacist. Get started today! Get started today! Review s at: Get started today! Review today! s at: Get started Review at: be sure have is easy. Whens go online, new ID hy. Review s at: Please don t wait. When If have questions or sure don t havehave is easy. go online, be access, toll-free at have new ID us hy. is easy.call When go online, be sureon backnew of ID card. One of our ember Service ID hy. Please don t wait. If have questions or don t have Representatives will be happy. be sure have is easy. When goto access, us toll-free atonline, onhave Please don t wait.call If have questions or don t new ID hy. back of ID card. One of ouratember Service access, call us toll-free on Representatives will be happy to ember. orservice back of don t ID card. One of our Please wait. If have questions don t have Representatives will us be toll-free happy toalp. access, call on back of ID card. One of our ember Service
2 Health safety services Health safety services Exclusive 24-hour access to. Exclusive access. Specialist 24-hour whotoare trained experienced in medications used to treat specific Specialist who are trained conditions. experienced in medications used to treat specific conditions. Safety alerts if a new may cause or medicationsmay we Safety harmful alerts if interactions a new with know re taking. cause harmful interactions with or medications we know Tips to re maketaking. taking medicine easier. Tips to make taking medicine easier. Worry-free services Worry-free services ree stard right to. ree stard right to. Receive 90-day supplies of multiple s in a single package. Receive 90-day supplies of multiple s in a single package. Automatically receive reminders by so never run out. Automatically receive reminders by so never run out. or complete details about, visit or calldetails us at ember on Card. or complete about Services, visitidentification or call us at ember Services on Identification Card. Note: If doctor prescribes a medication that is not on plan s preferred list, yet an alternative plan-preferred drug exists, we may contact doctor to ask wher that medication would be appropriate for. You ll usually pay less for a plan-preferred drug. Note: If doctor prescribes a medication that is not on plan s preferred list, yet an alternative plan-preferred drug exists, we may contact doctor to ask wher that medication would be appropriate for. You ll usually pay less for a plan-preferred drug. Blue Cross Blue Shield West Virginia is an independent licensee of Blue Cross Blue Shield Association. Blue Cross, Blue Shield Cross Shield symbols are registered service marks of Blue Cross Blue Shield Association. Blue Cross Blue Shield West Virginia is is aanregistered independent of Inc. Blue Cross Blue Shield Association. marklicensee of Blue Cross, Blue Shield Cross Shield symbols are registered service marks of Blue Cross Blue Shield Association. is a registered mark of Inc. for health plan. Express Scripts is an independent company that administers Express Scripts is an independent company that administers for health plan. LTR239401B 09/2014 LTR239401B 09/2014 LTR239401B 09/ Express Scripts Holding Company. All Rights Reserved. LH43774Q PCC385
3 Common questions about What is? Your offers of maintenance medications those need on a long-term basis right to door, with free stard shipping. (You should use a retail pharmacy for medications take on a short-term basis, such as antibiotics.) How easy is it to try? Very easy. Visit, sign in go to quick links icon ill Rx n choose which of current maintenance medications d like to receive through. Or can call us at on ID card. We ll take care of rest. Do I need to call my doctor about this? ost people prefer to have us contact ir doctor to get a new 90-day for. Just get started as described above, we ll follow up with doctor if necessary. How long will it take to get my medication? When fill a through for first time, should receive medication within two weeks after Express Scripts receives order. Refills are usually processed sooner within 3 to 5 days. Blue Cross Blue Shield West Virginia is an independent licensee of Blue Cross Blue Shield Association. Blue Cross, Blue Shield Cross Shield symbols are registered service marks of Blue Cross Blue Shield Association. is a registered mark of Inc. Express Scripts is an independent company that administers drug for health plan Express Scripts Holding Company. All Rights Reserved. EE24364 BR45160K Home : Enhanced pharmacy care, convenience cost savings Join millions of ors who have chosen to get ir medications delivered at, for less. Home from Express Scripts Pharmacy S can stay healthy lower costs. It s all part of at door at fingertips.
4 To save time money on drugs, choose today. You ll get up to a 90-day supply of maintenance medications, with free stard shipping. Health safety support Cost-saving services At- convenience Online services Our are available 24/7 to answer medication questions. Specialist have in-depth training in medications used to treat specific conditions, such as high blood pressure, high cholesterol diabetes. You ll typically pay less by getting up to a 90-day supply. Savings notifications let know when have new ways to save. Prescription specialists can find or cost-saving opportunities, such as using generics. Enjoy free stard right to. Automatically receive reminders by so never run out. Refill medication by phone or online. With permission, we will contact doctor when it s time to renew. Track s s. View claims, balances history. Receive alerts if re s a -related safety issue. Get started with review online s. Visit
5 HOE DELIVERY ORDER OR *6101* 1 ember : Please verify or provide below. OLD HERE OLD HERE ember ID: Group: Name: Street Address: Street Address: Street Address: City, ST, ZIP: Daytime phone: 2 3 (Express Scripts will keep this address on file for all orders from this ship until anor shipping address is provided by any person in this ship.) Patient/doctor : Complete one section for each person with a. If a person has s from more than one doctor, complete a new section for each doctor (additional sections are on back). Send all s in envelope provided. irst name Birth date (/DD/YYYY) irst name Birth date (/DD/YYYY) Patient s relationship to 1st initial Patient s relationship to 1st initial Doctor s phone Doctor s phone Complete order: You can pay by e-check, check, money order, or credit card. ake checks money orders payable to Express Scripts, write ID on front. You can enroll for e-check payments price medications at Express-Scripts.com, or call ember Services phone found on ID card. Number of s sent with this order: Please send me notices about status of enclosed (s) online ordering New shipping address: Evening phone: Payment options: e-check Payment enclosed Credit card Send bill or credit card payments: Visa C Discover Amex Diners Expiration date X Y Y Cardholder signature Credit card I authorize Express Scripts to charge this card for all orders from any person in this ship. Rush mailing of this shipment ($21, cost subject to change). NOTE: This will only rush shipping, not processing of order. Street address is required; P.O. box is not allowed. LROHNW ailing instructions are provided on back of this form.
6 Patient/doctor continued irst name Birth date (/DD/YYYY) Patient s relationship to 1st initial Doctor s phone irst name OLD HERE OLD HERE Birth date (/DD/YYYY) Important reminders or Check that doctor has prescribed maximum days supply allowed by plan (not a 30-day supply), plus s for up to 1 year, if appropriate. Also, ask doctor or pharmacist about safe, effective, less expensive generic drugs. Complete Health, Allergy & edication Questionnaire. There may be a limit to balance that can carry on account. If this order takes over limit, must include payment. Avoid delays in processing by using e-checks or a credit card. (See Section 3 for details.) If are a edicare Part B beneficiary AND have private health insurance, check drug materials to determine best way to get edicare Part B drugs supplies. Or, call ember Services at phone found on ID card. To verify edicare Part B coverage, call edicare at Patient s relationship to 1st initial Doctor s phone Express Scripts will make all possible efforts, as appropriate by law, to substitute generic formulations of medication, unless or doctor specifically directs orwise. Pennsylvania Texas laws permit to substitute a less expensive generic equivalent for a br-name drug unless or doctor directs orwise. Check box if do not wish a less expensive br or generic drug. Please note that this applies only to new s to any s of that. or additional or, visit us at Express-Scripts.com or call ember Services at phone found on ID card. TTY/TDD users should call ederal law prohibits return of dispensed controlled substances. Place (s), this form, payment in envelope provided. Be sure address shows through window. Do not use staples or paper clips. EXPRESS SCRIPTS PO BOX CINCINNATI, OH LROHNW
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