Aetna Order Form – Fill Out and Use This PDF

Order Form

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

SECTION A

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

SECTION B

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.

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.

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

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.