How to Order

Talk to your doctor

Your prescription will be filled for the exact quantity prescribed by your doctor. With this in mind, ask your doctor to write your prescriptions for a 90-day supply* with the appropriate number of refills.

Discuss with your doctor, the possibility of prescribing generic medication. You may be able to reduce your health care cost by the use of generic medication.

*Texas state law prohibits filling prescriptions for a quantity greater than for what the original prescription was written.

Placing an Order

· Internet: Order refills online thru our Mail Service partner PrecisionRx

· Mail: For new prescriptions, mail your written prescription, the completed Order Form and Patient Profile, and payment to the address below. For refills, just complete and mail your ReOrder Form** and payment to:

RxAmerica
c/o PrecisionRx
P.O. Box 961025
Fort Worth, Texas 76161-9863

**A ReOrder Form is included with the delivery of each order.

· Phone: Refill orders only may be phoned in to 1-800-293-2202.*** Payment by credit card is required.

· Doctor Fax: Simply have your doctor fax your prescription to PrecisionRx at 1-800-905-9815.***

***Texas state law prohibits receiving out of state prescriptions for controlled medications by fax or over the phone. The original hard copy must be mailed in for controlled medications. Check with your doctor to see if your medication is considered a controlled medication.

Payments

For your convenience, you may charge your purchase with a Visa, MasterCard, American Express, or DISCOVER Card on phone and Internet orders, or you may also elect to send a check or money order with a mailed prescription.

ALWAYS ALLOW 14 DAYS TO RECEIVE YOUR ORDER, FROM THE DAY OF MAILING YOUR PRESCRIPTIONS OR PLACING YOUR ORDER BY PHONE.

Signature Requirements

Certain prescription drug items require an adult signature upon delivery.

Shipping and Handling

The Mail Service ships to all 50 states. Shipping charges may apply to customers outside mail service insurance plans. Special shipping is available at the member’s request.
Special shipping charges are:

· Next business day delivery $15.00

· Next day Saturday delivery $30.00

1. Complete this form on your screen.

2. Verify that all entered information is correct. DRUGCARD - DRX

3. Print this page on your printer.

4. Sign the printed order form.

5. Enclose the order form with your check or money order (payable to PrecisionRx) if you are not paying by credit card.

6. Address the envelope, affix proper postage, and mail to the address below.

RxAmerica
c/o PrecisionRx
P.O. Box 961025
Fort Worth, TX 76161-9863

Enrollee Name:
Enrollee ID Number:   Date of Birth:
Drug Allergies: None   Penicillin   Codeine   Sulfa   Aspirin   Other
Plan Name:
Spouse Name:
Drug Allergies: None   Penicillin   Codeine   Sulfa   Aspirin   Other
Address:
City:       State:       Zip:
Daytime Phone: -        Home Phone: -
I would like child-proof caps   Yes   No    Child-proof caps are used for safety in shipping.
Substitute for Generic drug, where applicable   Yes   No (No, may result in a higher copay)
Doctor's Name:
Doctor's Phone Number: -

Payment Method:
   Check or Money Order       Visa       MasterCard       Discover       American Express
Credit Card Number:   Expiration Date:
Number of prescriptions enclosed:   Total copay amount enclosed $

I certify that the information on this form is correct, and authorize the release of all information to the plan administrator.
Signature: (required) Date:

ATTACH DEPENDENT INFORMATION

DEPENDENT INFORMATION: Complete all applicable information for your dependent children.
(If listing more than one child, attach a separate page with the needed information.)
Child Name:
Date of Birth: mm/dd/yyyy Gender:
Drug Allergies: None Penicillin Codeine Sulfa Aspirin Other
Doctor's Name:
Doctor's Phone Number: -