CIGNA s Home Delivery Pharmacy Program

Transcription

1 CG s Home elivery Pharmacy Program our pharmacy needs are administered by CG Pharmacy. ou are encouraged to consider CG s Home elivery Pharmacy program if you are taking prescription medications on an ongoing basis. his includes all classes of medications; even controlled substances. CG s Home elivery Pharmacy is managed just like the pharmacy on the corner. pharmacist oversees and handles your prescription just like he or she would at the local drug store. he CG Home elivery pharmacist checks for any possible interactions with medication you are currently taking and will contact your doctor if there are any concerns or questions. our medications are shipped to you at your home or other preferred location at no cost to you. ven medications requiring refrigeration or other special handling are shipped to you at no additional cost. our medication will arrive promptly and safely. here are other advantages to using the CG Home elivery Pharmacy. licensed pharmacist is available 247. ou can sign up for reminders if you forget to order your refills. ou can receive a 90day prescription for a 60day copay amount. ou can download the order form, and track orders and ship dates through your secure sign on at ou can get all your prescriptions by mail and noncontrolled substance medications by phone. When you log in to you can use the Prescription rug Price Quote tool on the pharmacy home page or call Option 1, ext 509 to get a price quote. o order your prescription by mail, just follow these simple steps: 1. Get a prescription from your doctor a. 90day with refills for maintenance drugs is best b. Controlled substances days supply is set by your doctor, but by law you are not allowed to have refills. ach order must be done by with an original prescription from your doctor. 2. ownload the order form from 3. ail the completed form along with the prescription and payment to CG Home elivery Pharmacy PO Box 1019 Horsham, P Please allow 7 to 10 days for your drugs to be delivered once your order is received. o order your prescription by phone, just follow these simple steps: 1. Have your medication, doctor s name, and credit card information available 2. Call , Option 1, ext he technician will take your information and will contact your doctor to request a prescription with refills. Please allow 7 to 10 days for your drugs to be delivered. * *O: Controlled substances cannot be ordered by phone because an original prescription is required with each order.

2 CG Home elivery Pharmacy Quick acts for your ongoing prescription medications *avings are based on a 90day fillrefill and are subject to your plan s provisions. our benefit plan may differ based on state law. Please check your plan documents for more details and to confirm that you have the CG Home elivery Pharmacy Benefit. CG elrug and the ree of ife logo are registered service marks, and CG Home elivery Pharmacy is a service mark, of CG ntellectual Property, nc., licensed for use by CG Corporation and its operating subsidiaries. ll products and services are provided exclusively by such operating subsidiaries, including elrug, nc. and elrug of Pennsylvania,..C., and not by CG Corporation. CG elrug and CG Home elivery Pharmacy refer to elrug, nc. and elrug of Pennsylvania,..C CG 14 point for Brochure and PP inside 21 point for PP cover

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4 CG Home elivery Pharmacy Prescription Order orm * * Please complete this form for W and prescription medication. ou can also order refills online at the website on your card. Print all information clearly as shown in the sample below using BU or BCK ink BC ill in the applicable ovals completely ( ). tep 1: nsurance Cardholder nformation B P H O # P H O # Complete if above has changed or appears blank Person completing Order updates, reminders and other educational information may be sent to the address above for the following individuals: 1 2 C Z P tep 2: llergies & Health Conditions ew customers must complete this section. f left blank will indicate no known drug allergies or no change from information provided previously to CG Home elivery Pharmacy. ame (start with cardholder) Complete this section every time ate of Birth ddress above is a one time address one Penicillin ulfa llergies Codeineorphine spirin rythromycin Other (list below) iabetes Health Conditions High Blood Pressure sthma GG High Cholesterol Other (list below) Please write the individual s name and list their other allergies and other health conditions referenced above: ev he ree of ife logo is a registered service mark, and CG Home elivery Pharmacy is a service mark, of CG ntellectual Property, nc., licensed for use by CG Corporation and its operating subsidiaries. ll products and services are provided exclusively by such operating subsidiaries, including elrug, nc. and elrug of Pennsylvania,..C., and not by CG Corporation. CG Home elivery Pharmacy refers to elrug, nc. and elrug of Pennsylvania,..C.

5 tep 3: hipping ethod tep 5: efill Prescriptions ffix label O complete requested information * * efrigerated shipments will be expedited at no additional cost. ou are responsible for the cost of PC HPPG which expedites carrier delivery time only. Order processing is not affected by PC HPPG. hese costs may be subject to change by carrier without prior notification and may vary depending on weight and zone. tandard hipping $0.00 UP Priority ail 2 3 ays $9.25 Overnight elivery $17.95 tep 4: ethod of Payment Check V oney Order otal payment enclosed (excluding credit card payment): astercard iscover merican xpress Use Credit ebit Card on ile Please make check or money order payable to CG Home elivery Pharmacy Credit ebit Card # ast 4 digits of Credit ebit Card authorize CG Home elivery Pharmacy to bill my credit debit card for this and all future orders. understand that my credit debit card will be billed the following amounts in effect at the time my order is filled: any applicable copayment(s), coinsurance andor deductible(s), payments due for any medications not covered under my benefit plan, plus any special shipping costs. $,. xpiration ate xpiration ate Print Prescription umber Here Print Prescription umber Here ndividual s ame ate of Birth rug ame ndividual s ame ate of Birth rug ame Print Prescription umber Here Print Prescription umber Here ndividual s ame ate of Birth rug ame ndividual s ame ate of Birth rug ame tep 6: ew Prescriptions nclose original written prescription from your doctor Please write the date of birth and the ember on the back of each prescription. Check ( ) One Check ndividual s ull ame ate of Birth ill ow o ot ill ow edication ame & trength ( ) if Brand Only octor s ull ame Pharmacy law permits pharmacists to substitute a less expensive generically equivalent medication for a brand name medication unless you or your doctor indicate otherwise. By checking ( ) Brand Only, you may incur a higher cost. emember to enclose the original prescription(s) from your doctor(s). ou can call us at or visit the website on your card. ou can also write to us or mail this order form to CG Home elivery Pharmacy, PO Box 1019, Horsham P