PD903991. 7/10. Medco Pharmacy™. MAIL-ORDER FORM. Please send me e-
mail notices about the status of the enclosed prescription(s) and online ordering ...
Your prescription may be processed by any pharmacy within our family of
Express Scripts mail-order pharmacies. TRICARE is a registered trademark of the
Medco Pharmacy®. *6101*. MAIL-ORDER FORM. Member information: Please
verify or provide Member information below. 1. FOLD HERE. FOLD HERE.
www.hillsmaterials.com/PDF/Medco - Mail-In Prescription Form.pdf
To order by mail: Include your refill slip(s) with this form. Do not complete the ... of
the mail service pharmacy on the front of the envelope and mail to Medco.
order form and your copayment in the enclosed return envelope. Be sure to fold
... By choosing to use Medco By Mail to fill your prescription, you are choosing to
To order by mail: Include your refill slip(s) with this form. Do not complete the ...
money order made payable to Medco Health Solutions, Inc. RxGrp: UH0712959.
The provision of the information requested in this form is for your patient's benefit.
Express Scripts does not compensate for completing this form. The Medco ...
With Medco's mail order pharmacies, you'll get: Up to a 90-day ... If you plan to
mail in your first prescription, download and print the Medco By Mail Order Form.
Mailing instructions are provided on the back of this form. 3 ... orders payable to
Medco Health Solutions, Inc., and write your member ID number on the front.
Mailing instructions are provided on the back of this form. FO. LD. H. ER. E ...
Complete your order: You can pay by e-check, check, money order, or credit card