Aetna Order Form PDF Details

Navigating the path to convenient medication delivery has been made simpler with the Aetna Order Form, designed for both first-time customers and returning ones to use Aetna Rx Home Delivery®. For newcomers, the procedure is straightforward: fill out Sections A, B, and C, complete the Patient Registration Form, and mail these along with your prescriptions and payment to the designated address. Every prescription must bear your name, address, date of birth, and member ID for identification. For those already using the service, the process remains nearly the same, with the added ease of placing refill orders online or by phone, and an option to change your shipping method for a rushed delivery at an additional charge. Aetna promotes both ease and flexibility, allowing the substitution of FDA-approved generic medications to ensure cost-effectiveness, unless specifically requested otherwise by the customer, which might lead to a higher copay. Furthermore, the form guides users through payment options, including checks, money orders, and various cards, with a clear intention to streamline the payment process and ensure timely processing of orders. Special attention is given to members with flexible spending accounts or those enrolled in specific Aetna plans, highlighting Aetna's efforts to accommodate diverse financial arrangements. The comprehensive nature of the form even extends to capturing family member information for any potential drug interaction check, thus prioritizing safety alongside convenience.

QuestionAnswer
Form NameAetna Order Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
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Form Preview Example

Order Form

Simply follow these easy steps to start using Aetna Rx Home Delivery®:

First Time Customers New Prescriptions

1.Complete Sections A, B and C of the Order Form.

2.Complete the Patient Registration Form.

3.Mail the Order Form and Patient Registration Form with your prescription(s) and method of payment to us. Please print your name, address, date of birth and member ID on each prescription.

Please mail all orders to:

Aetna Rx Home Delivery

P.O. Box 829518

Pembroke Pines, FL 33082-9913

Returning Customers New Prescriptions or Refills of existing prescriptions

1.Complete Sections A, B and C of the Order Form.

2.Complete the Patient Registration Form ONLY if your member information has changed.

3.Mail the Order Form and Patient Registration Form with your prescription(s)

and method of payment to us. Please print your name, address, date of birth and

member ID on each prescription.

Refill orders can also be placed by visiting www.aetna.com/aetnarxhomedelivery

or by calling 1-800-227-5720 (TDD: 1-800-823-6373).

Method of Delivery: ❏ Standard ❏ Rush (additional charges apply)

SECTION A

Your Name

 

 

Date of Birth

 

 

 

 

 

 

Your Aetna Member ID

 

 

Medicare Part B# (if you have one)

 

 

 

 

 

 

Home Address

 

City

State

ZIP

 

 

 

 

 

Check here if home address is new

 

 

 

 

 

 

 

 

Day Phone

Evening Phone

Cell Phone

E-mail

 

 

 

 

 

 

Shipping Address (If different than home address) Please note: Address information entered here will only be used for this order.

Name

Address

City

State

ZIP

SECTION B

Name

Aetna Member ID

Medication Name and Strength

Prescribing Physician Name and Phone Number

Brand Only If Ordering a Refill: Enter

(X)Refill Numbers Below

We will automatically substitute FDA-approved generic medications for brand-name medications when (1) a generic equivalent medication is available and (2) your doctor’s prescription instructions allow. If you do not want us to substitute a generic, you must check “Brand Only” above for the medication(s) you want dispensed as brand only. If a member chooses a brand-name drug when a generic alternative is available (regardless of the reason), they may be subject to a higher copay.

In most instances, we are unable to provide refunds for returned medications. If you have questions about your order or our return policy, please call Customer Service at 1-800-227-5720.

SECTION C

To estimate the cost of your medications, visit www.aetna.com and log in to AetnaNavigator™. Look for the “Take Action on Your Health” tab, then select “Cost of Care.” The cost of your medication can be found on the “Prescription Drugs” link. You may also call the toll-free number on your Aetna member ID card for medication cost information.

Method of Payment: Make a check or money order payable to Aetna Rx Home Delivery or use your personal credit or debit card. Please do not send cash. Important Information:

If you do not include a method of payment with your order and a previous order was paid for by credit or debit card, we will use that credit or debit card as the method of payment on this order.

If you have an unpaid balance with our pharmacy this order may not be processed until payment is received.

If you have a Flexible Spending Account (FSA) auto-debit feature, or are enrolled in an Aetna HealthFund® or Vital Savings on HealthSM plan, please provide a personal credit or debit card to cover any expenses that may exceed your account balance.

If you are enrolled in an FSA, Health Savings Account (HSA) or Vital Savings on Health program and have a FSA/HSA/Vital Savings on Health debit card, you can use your card for payment (please also provide a personal credit or debit card to cover any expenses in excess of your account balance).

Providing a credit or debit card will help prevent delays in order processing that result from insufficient payment.

MC/VISA/AmEx/Discover or debit card number

Expiration Date

FSA/HSA debit card number

Expiration Date

 

 

Cardholder Name

Signature

The credit and/or debit cards used in processing this order will be billed for medication order costs, rush shipping costs (if applicable) and any outstanding balances. They will also be billed for all future orders unless you provide a different form of payment.

Total amount enclosed (if paying by check or money order)

18.09.308.1-FL WEB (1/08) S5810_7D_50931 (1/2006)

Fill out thefollowing section if this is your first order with Aetna Rx Home Delivery or if this information has changed.

Please complete the following for EACH family member covered under your Aetna pharmacy benefit. Select “None” for family members with no allergies or health conditions. For your convenience, this information will be included as part of your family’s profile with Aetna Rx Home Delivery. We will use this information to check for potential drug interactions and allergies to medications.

For the fields below, mark with an (X) unless otherwise noted.

Member Information

Allergies

Health Conditions

 

 

FAMILY MEMBER NAME

Spanish preferred*

Date Of Birth

(MM/DD/YYYY)

Gender (M/F)

Relationship to Subscriber (S)pouse, (C)hild, (O)ther

None

Penicillin

Sulfa

Aspirin

Thyroid

Diabetes

Glaucoma

Heart Conditions

High Blood Pressure

Ulcer

Epilepsy

FAMILY MEMBER NAME

Other allergies or health conditions not listed above (please specify)

If you or a family member has diabetes, indicate the type of supplies being used below:

Name

Monitor

Lancets

Test Strips

Number of tests per day

If you have secondary insurance through another carrier, check here

Please note: By submitting this form, you authorize the release of all the foregoing information to Aetna Rx Home Delivery, LLC, and its affiliates.

Aetna Rx Home Delivery now offers our customers the ability to make payments over the phone for balances due. If you would like to use this payment option, let our Customer Service Associate know and your bank account will be electronically debited for the balance due. The first time you use this service, our Associate will ask you to verify your name, address and some additional information to help us uniquely identify you and secure your transaction. You will then be asked to select a User ID and authorization number, which will be required for future “check by phone” transactions.

When you provide a check as payment, you authorize us to use information from your check either to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day [you make] [we receive] your payment[, and you will not receive your check back from your financial institution].

Please note Aetna Rx Home Delivery's standard shipping practice is to send all medication orders on an account to the health plan subscriber. For example, a family member's order will be sent to the subscriber's address. If you wish to make alternative shipping arrangements please call Customer Service.

*For your convenience, Aetna Rx Home Delivery maintains a staff of Spanish-speaking customer service representatives.

18.09.308.1-FL WEB (1/08)

S5810_7D_50931 (1/2006)

 

©2008 Aetna Inc.

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example of blanks in aetna order form

Feel free to complete the SECTION C To estimate the cost of, card as the method of payment on, If you have an unpaid balance, provide a personal credit or debit, If you are enrolled in an FSA, card you can use your card for, Providing a credit or debit card, MCVISAAmExDiscover or debit card, FSAHSA debit card number, Cardholder Name, Signature, Expiration Date, Expiration Date, The credit andor debit cards used, and FL WEB SD space with the essential data.

part 2 to filling out aetna order form

Write down the key data in Member Information, Allergies, Health Conditions, d e r r e f e r p h s i n a p S, h t r i B f O e t a D, FAMILY MEMBER NAME, Y Y Y Y D D M M, F M, r e d n e G, r e b i r c s b u S o t p h s n o, r e h t O, l i, h C, e s u o p S, and i l l i c i n e P part.

stage 3 to entering details in aetna order form

When it comes to part If you or a family member has, Name, Monitor, Lancets, Test Strips, Number of tests per day, If you have secondary insurance, Aetna Rx Home Delivery now offers, When you provide a check as, Please note Aetna Rx Home, For your convenience Aetna Rx Home, FL WEB SD, and Aetna Inc, state the rights and obligations.

aetna order form If you or a family member has, Name, Monitor, Lancets, Test Strips, Number of tests per day, If you have secondary insurance, Aetna Rx Home Delivery now offers, When you provide a check as, Please note Aetna Rx Home, For your convenience Aetna Rx Home, FL WEB  SD, and Aetna Inc fields to fill out

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