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New E Rx Order form qxd refill

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					Anthem Rx Order Form
For Lilly employees and retirees

Easy and Convenient

Convenience — make fewer
trips to the pharmacy
Ordering maintenance
medications through Anthem Rx
eliminates monthly trips to the
pharmacy because your doctor
can write prescriptions for your
plan’s maximum allowable days’
supply. (See your plan Health
Certificate or Evidence of
Coverage.) Your prescriptions can
then be ordered through Anthem
Rx mail service and delivered
directly to your home, office or
anywhere in the United States.

Savings — save on copayments
Anthem Rx mail service normally
provides more days’ supply with
lower copayments. You’ll              Did You Hear the News?                Whats does this mean?
typically save money on each
                                                                            Anthem Rx is now able to display
prescription filled by the Anthem     In an effort to deliver the best in   the VIPPS seal of approval.
Rx mail pharmacy.                     customer service and prescription
                                      medication convenience,
                                                                            The VIPPS seal is designed to help
Safety — protection through           Anthem Rx is proud to announce
                                                                            ensure your private information
drug utilization review               our VIPPSTM certification.
                                                                            remains well-protected, including
                                                                            prescription drug history, orders,
After you complete the short,
                                                                            shipping address and credit
confidential order form,              What is VIPPS?
                                                                            card data.
Anthem Rx will screen your
                                      VIPPS stands for Verified Internet
prescriptions against our claims                                            Remember, the VIPPS seal is
                                      Pharmacy Practice Sites.
information for possible allergies,                                         intended to provide you with
interactions, duplications or         The National Association of           secure and top-notch
other potential problems.             Boards of Pharmacy®’ (NABP)           prescription drug services.
                                      awards the VIPPS designation
                                      to properly licensed online
                                      pharmacies that have successfully      Thank you for your order.
                                      completed a rigorous review
                                                                             We appreciate your business. Thank
                                      and inspection.
                                                                             you for allowing Anthem Rx to fill
                                                                             your prescription drug needs.




MBCEFRM-73 Rev. 3/06                                    1
                                                                                                                              Please tear here.
Placing Orders for New Prescriptions                          Refills: Three Simple Ways
1. Contact your physician for a new prescription,             Important: To help ensure that you do not run out
   written for your maximum allowable supply.                 of your medication, please place your refill order on or
   Your plan allows 100 days.                                 after the “due after” date indicated on your refill label.
2. If you would like your prescription to be filled
   with a generic medication, place an “X” in the             By Internet:
   box at the top of the easy-order form where it says        1. Log in on our Web site at www.anthem.com and
   “Please check this box if you wish to receive                 click on Pharmacy Services.
   geneic medications.” Your physician must write             2. Submit a request for reorder over a secure
   the prescription indicating generic fill is allowed.          connection.
   Lilly will fill with a Brand medication unless               If you do not have Internet access, call
   directed to fill generic.                                    1 (800) 962-8192, Monday-Friday, 8:30 a.m.-11 p.m.
3. Complete the enclosed easy-order form.                       or Saturday, 9 a.m.-7 p.m., Eastern time, to speak to a
  Instructions:                                                 customer representative.
  - To avoid delays when processing your order,               (Once your credit card number is on file, you can order
    please be sure to fill out all fields completely.         24 hours a day through the Anthem Rx Web site or
                                                              by using our automated phone line.)
  - Please use blue or black ink.
                                                              3. For Lilly specific assistance, please call
  - Do not use red ink.                                          1 (888) 730-2832 to speak with a representative.
  - Print clearly and avoid making stray marks.
  - Please attach address and refill labels in fields
                                                              By Phone:
    as indicated.                                             1. Have your prescription label ready.
4. Send the ORIGINAL prescription, the                        2. Call 1 (800) 962-8192.
   completed form and proper payment in                         Press 3 for automated ordering. Have your
   the envelope provided.                                       7-digit number from your prescription label ready.
5. If you are unsure of payment, please call                    Press 2 to check an order’s status.
   1 (800) 962-8192 for a price quote before sending            Press 0 to talk directly to a customer
   in your order. (automated service is also available)         service professional.
6. For Lilly specific assistance, please call                   Customer Service Hours:
   1 (888) 730-2832 to speak with a representative.             Monday-Friday, 8:30 a.m.-11 p.m.,
                                                                Saturday, 9 a.m.-7 p.m., Eastern time
OR                                                            (Once your credit card number is on file, you can order
                                                              24 hours a day through the Anthem Rx Web site or
Contacting Physician via Fax                                  by using our automated phone line.)
If you do NOT have your written prescription(s),              3. For Lilly specific assistance, please call
a special number is available for members who have               1 (888) 730-2832 to speak with a representative.
never used Anthem Rx. To start receiving your
current prescriptions via mail service, simply:               By Mail:
1. Have your prescription information (name of                1. Complete the attached order form and affix the
   prescription and milligram), with your doctor’s               refill label or write the prescription refill number
   name and phone number, and method of                          in the area provided.
   payment (VISA®, MasterCard, American Express               2. Return the order form with the proper payment.
   or Discover Card) ready.
2. Call, toll free 1 (888) 613-6091, Monday                     For speech- and hearing-impaired assistance, (TDD/TTY),
   through Friday, 8:30 a.m.-5 p.m., Eastern time.              call 1 (800) 221-6915. M-F, 8:30 a.m.-5 p.m., Eastern time.
3. We will guide you through the process.
                                                                                                                              Please tear here.




                                                          2
                                                                                                       2003-174-6S (7/04)
           Please check this box if you wish
           to receive generic medications.
Ship to:
Cardholder’s ID no.                                                                 Cardholder’s Name (Last)                             (First)
                                                              ATTACH ADDRESS
Cardholder’s Date of Birth          E-mail address (optional) LABEL HERE     Street                                                                                Apt. no.
      /         /
Phone - Daytime                             Phone - Evening                         City                                                             State      ZIP code
           /           -                                /             -
Payment information: Payment must be included with order. Make check or money order payable to Anthem Rx. There is a $25 fee for returned checks.
Method of payment
    Check     VISA    MC      Discover      AMEX      Account no.               -            -                           -               Exp.date: Mon.            Yr
Total amount due*  *If you miscalculated the “total amount due,” your card will automatically               Please sign for credit card order
                    be billed the correct amount. Please check your invoice when this
$             .     prescription arrives for the actual amount billed to your card.

New prescription orders (no need to fill out for refills):
Name on prescription (Last)                                 (First)                                            Date of birth                       Drug allergies
                                                                                                                     /         /                      Penicillin        Cephalosporins
Sex                 Relationship to cardholder              Have you taken this medication before?             Do you prefer safety caps?             Sulfa             Acetaminophen
M X F X          Self      X   Spouse   X   Child   X        Y X N        X                                    Y X N X                                Codeine           Trimethoprim
Doctor’s name (Last)                                        (First)                                            Phone no.                              Aspirin           Morphine
                                                                                                                         /       -                    NSAID
Health conditions                                                             Other medications being taken (including over-the-counter)
                                                                                                                                                      Other


Refill orders (see instructions on page 2):
Refill number                  Medication name                                                   Refill number                 Medication name
                                        TO REORDER, PLACE REFILL LABEL HERE                                                          TO REORDER, PLACE REFILL LABEL HERE
Name on prescription (Last)                                 (First)                              Name on prescription (Last)                         (First)

Refill number                  Medication name                                                   Refill number                 Medication name
                                        TO REORDER, PLACE REFILL LABEL HERE                                                          TO REORDER, PLACE REFILL LABEL HERE
Name on prescription (Last)                                 (First)                              Name on prescription (Last)                         (First)
Save Time!                                                OR
Get your prescription refills faster using your           By Internet:
telephone or computer!                                    1. Log in on our Web site at www.anthem.com and
You can order refills 24 hours a day with a VISA,            click on Pharmacy Services.
MasterCard, American Express or Discover Card credit      2. Submit a request for reorder over a secure
card number. Anthem Rx offers these convenient options       connection.
for ordering prescription refills.                           If you do not have Internet access, call
                                                             1 (800) 962-8192, Monday-Friday, 8:30 a.m.-11 p.m.
By Phone:                                                    or Saturday, 9 a.m.-7 p.m., Eastern time, to speak to
1. Have your prescription label and credit card ready.       a customer representative.
2. Call 1 (800) 962-8192 and select the “automated        3. For Lilly specific assistance, please call
   refill order line” option from the menu.                  1 (888) 730-2832 to speak with a representative.
3. Follow the prompts to place your order.                Speech- and hearing-impaired users with
   Customer Service Hours:                                a TDD/TTY system can call 1 (800) 221-6915,
   Monday-Friday, 8:30 a.m.-11 p.m.,                      Monday-Friday, 8:30 a.m.-5 p.m., Eastern time.
   Saturday, 9 a.m.-7 p.m., Eastern time
4. For Lilly specific assistance, please call
   1 (888) 730-2832 to speak with a representative.

                              Fold on dotted line and slip into envelope provided.




Instructions for Folding Form

1. Tear off form.
                                        s4527460002s




2. Fold on lines provided on back and slip form into envelope with proper payment.                           s4527460002s




3. Do not staple, tape or paperclip anything to order form.
                                                                    s4527460002s




                              Fold on dotted line and slip into envelope provided.



For Members                                              For Providers

Did you remember to:                                     Did you remember to:
• include your payment?                                  • include the patient’s name, date of birth
                                                           and cardholder ID number on each enclosed
• enclose your prescription(s) or attach
                                                           prescription?
  refill label(s)?
                                                         • date and sign each prescription?
• indicate the address to which you would like
  your order shipped?                                    • write each prescription according to allowed
                                                           plan benefits?




Rev. 3/06

				
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Description: New E Rx Order form qxd refill