You may pay less for medications with home delivery.
You could enjoy extra member-only savings with home delivery from OptumRx®, your plan’s home delivery pharmacy. When you use home delivery, you save a trip to the local pharmacy, and you can talk to a pharmacist anytime.
It’s easy to get started. 1
Order a three-month supply of your maintenance medication.1 Visit myuhc.com or call OptumRx at the number on your member ID card.
2
OptumRx fills your order and mails it to you.
3
The medication arrives within 7–10 days. You pay nothing for standard shipping.
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Sign up for home delivery today. Visit myuhc.com to get started. For a personal consultation to find out if you can save, call OptumRx at the number on your member ID card, 24 hours a day, 7 days a week.
New PrescriPtioN Mail-iN order ForM
1
Member and physician information — please use black or blue ink. one form per member. Member ID Number
You can also complete the enclosed form and mail it to: OptumRx P.O. Box 2975 Mission, KS 66201
(Additional coverage, if applicable) Secondary Member ID Number
If you’re not completely happy, you can switch back to your local pharmacy at any time.
Last Name
First Name
MI
Delivery Address
SAVE MONEY. • You could pay less for three-month supplies of your maintenance medication
Apt. #
City
State
ZIP
• No charge for standard shipping Phone Number with Area Code
SAVE A TRIP. • No need to drive to your local pharmacy
Date of Birth (mm/dd/yyyy)
• Order and track your prescriptions with the Health4Me® App2 on your smartphone
Physician Phone Number with Area Code
•2 4/7 phone access to a pharmacist who can help answer your medication questions
2
Find out if you will save with home delivery. Visit myuhc.com.
Email
Physician Name
YOUR HEALTH COMES FIRST. • Avoid missing a refill with phone, text3 and email reminders
Gender M F
Health history Medication Allergies: Aspirin None known Cephalosporins Amoxil/Ampicillin Codeine
Erythromycin NSAIDs Penicillin
Quinolones Sulfa Tetracyclines
Others:
Health Conditions: None known Arthritis
Glaucoma Heart condition High blood pressure
High cholesterol Osteoporosis Thyroid Disease
Others:
Asthma Cancer Diabetes
Over-the-counter/herbal medications taken regularly:
3
Payment and shipping information — do not send cash Standard delivery is included at no charge. New prescriptions should arrive within about 10 business days from the date the completed order is received. Completed refill orders should arrive within about 7 business days. OptumRx will contact you if there will be an extended delay in delivering your medications.
Or call OptumRx at the number on the back of your member ID card. 24 hours a day, seven days a week.
You may log on to optumrx.com to see if drug pricing information is available before enclosing payment. Once shipped, medications may not be returned for a refund or adjustment. Ship overnight. Add $12.50 to order amount (subject to change). Check enclosed. All checks must be signed and made payable to: OptumRx. Charge to my credit card on file. Charge to my NEW credit card.
Maintenance medication is the medication you take regularly for a chronic or long-term condition.
1
App is available for download on both Apple® and Android™ devices.
2
OptumRx provides this service at no additional cost. Standard message and data rates charged by your carrier may apply.
3
UnitedHealthcare® and the dimensional U logo are registered trademarks owned by UnitedHealth Group Incorporated. All branded medications are trademarks or registered trademarks of their respective owners. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by UnitedHealthcare Insurance Company, United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company.
New Credit Card Number
Expiration Date (Month/Year)
Visa, MasterCard, AMEX and Discover are accepted.
Signature: Date: For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such expenses related to prescription orders. By supplying my credit card number, I authorize OptumRx to maintain my credit card on file as payment method for any future charges. To modify payment selection, contact customer service at any time.
4
Mail this completed order form with your new prescription(s) to OptumRx, P.O. Box 2975, Mission, KS 66201. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.
New prescriptions should arrive within ten business days from the date the completed order is received by the Mail Service Pharmacy. Completed refill orders should arrive in about seven business days. OptumRx will contact you if there will be an extended delay in the delivery of your medications. © 2015 Optum, Inc. All rights reserved. UHC8986_160101
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