(Faxes can only be accepted from a doctor’s office.) Phone: Call Express Scripts at the toll-free number on the back of your ID card for assistance in switching to home delivery. Mail: …

HOME DELIVERY PHARMACY ORDER FORM To MAIL your prescription: “Patient” box must be filled out. Have your Doctor write a prescription. Send your new prescription along with this …

To FAX your prescription: 1.Have your Doctor fill out the bottom portion of this form. 2.Doctor can fax to: 800-875-6356 Class Il medications cannot be faxed. Faxed prescription can only be …

I permit Express Scripts Inc. to release all information on this form concerning prescription orders to my plan sponsor, administrator or health plan for the purpose of payment, treatment or …

Mailing instructions are provided on the back of this form. Check that your doctor has prescribed the maximum days’ supply allowed by your plan (not a 30-day supply), plus refills for up to 1 …

Express Scripts facsimile machines are secure and in compliance with HIPAA privacy standards. The provision of the information requested in this form is for your patient's benefit. Express …

Use this form to ask your doctor to write your prescription for up to a 90-day supply or the maximum days allowed by your plan with refills of up to one year, if appropriate.

Mail Fill out the home delivery order form (PDF) and then mail the form and your 90-day prescription to the address listed on the form.

Get your written prescriptions to us by using our mail order form. Find TRICARE claims forms, our medical questionnaire, and other important documents all collected in one convenient place.

Phone: Call Express Scripts at the toll-free number on the back of your ID card for assistance in switching to home delivery. Mail: Complete the order form and send to Express Scripts® …