Mail this form & payment to: Rx Outreach / PO Box 66536 / St. Louis
Transcription
Mail this form & payment to: Rx Outreach / PO Box 66536 / St. Louis
INSTRUCTIONS FOR REFILLS and NEW PRESCRIPTIONS Refills Online (You need a credit card to order online) Visit www.rxoutreach.org; sign in, your account activity will appear and those prescriptions available for refill will be listed under the Prescription Category. Check the refill box on those prescriptions you wish to refill and follow the remaining steps to complete you order. Refills by Phone (You need a credit card to order by phone) - Call 1-888-RXO-1234 (796-1234) from 7:00 am to 5:30 pm CT Monday Friday to place an order or use our automated system by calling 1-888-RXO-1234 24 hours a day/7 days a week Refills by Mail - Complete Sections A, B, and C below and mail the form and your payment to Rx Outreach New Prescriptions by Mail - Complete Sections B and C below and mail the form, your prescription, and payment to Rx Outreach To order controlled substances (CS), you must attach a copy of your photo ID card (for example, a driver’s license or state ID card) and a copy of your Social Security Card or Green Card. Controlled Substances will be shipped separately from other medications. CONTROLLED SUBSTANCES CAN NOT BE SHIPPED TO A PO BOX OR DOCTOR’S OFFICE. YOUR SHIPPING ADDRESS MUST BE A DELIVERABLE U.S. POSTAL SERVICE STREET ADDRESS. Controlled substance medications are only allowed up to a maximum of a 90-day (3 months) supply. If a doctor authorizes enough doses to be filled over 5 months (maximum allowed by law), the prescription is allowed 1 refill of a 90-day supply. Enrolling in Rx Outreach for the first time… Please complete the following information as well as the information in Sections B and C. Mail this form, your prescription(s), and payment to Rx Outreach. I attest that my income is at or below 300% of the federal poverty level. Annual income $___________ # in Household ______. I will not seek reimbursement of any fee I pay to Rx Outreach from my health insurance, including Medicaid, Medicare, or similar programs. Section A: Refills by Mail (use an additional sheet of paper if necessary) Please fill in the below section for refills by mail. Mark whether you would like a 90-day or 180-day supply for each medication listed. Not all medications are available in a 180-day supply (please refer to the enclosed drug list). If necessary, we may contact you or your doctor for additional information. Rx Number __________Product Name ___________________________ Rx Number __________Product Name ___________________________ Rx Number __________Product Name ___________________________ Rx Number __________Product Name ___________________________ Rx Number __________Product Name ___________________________ Rx Number __________Product Name ___________________________ 90-day: 90-day: 90-day: 90-day: 90-day: 90-day: ___ ___ ___ ___ ___ ___ 180-day: ___ 180-day: ___ 180-day: ___ 180-day: ___ 180-day: ___ 180-day: ___ Total $__________ Administrative Fee $__________ Administrative Fee $__________ Administrative Fee $__________ Administrative Fee $__________ Administrative Fee $__________ Administrative Fee $__________ Section B: Patient Information Soc Sec# / Green Card #/ or Rx Outreach #___________________________________ Date of Birth (MM/DD/YY) __ __/__ __/__ __ Last Name__________________________________________ First Name ______________________MI ______________________ Shipping Address ________________________________________________Apt #_____ Home Phone: _________________________ City ____________________________________________________________________ State _________ Zip Code: ______________ E-mail address: ________________________________________________________ Check this □ box if you would like to receive our newsletter. Doctor’s Name _______________________________________Dr. Phone #____________________Dr. Fax #____________________ Please list any food/medicines you are allergic to: _____________________________________________________________________ Please list all medicines you are currently taking and medical conditions: __________________________________________________ Section C: Payment Information - personal check, money order, credit card (Visa, MasterCard, Discover, or FSA account only) By check or money order: Make payable to Rx Outreach. (Please do not send cash) Amount Enclosed: $________ By credit card: Credit Card Number: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ Check type of credit card you are using: □ Visa □ MasterCard □ Discover □ FSA Exp.: ______- ______ Credit (check one) Debit Total Amount $_______ I authorize Rx Outreach to charge this credit card for payment. Name on card: ______________________________ Signature of cardholder: ______________________________________________ I acknowledge that the information on this form is true and correct. I consent to the release by my health care providers of my medication information pertaining to prescriptions for Rx Outreach to be used for program authorization purposes. Mail this form & payment to: Rx Outreach / PO Box 66536 / St. Louis, MO 63166-6536 ©2015 Rx Outreach. All Rights Reserved. Rev 04/15 RFRXO-0415 Rx Outreach Medication AcipHex® Acyclovir Alendronate (1/week dosage) Allopurinol Alprazolam (CS) Amitriptyline Amlodipine Aricept® Atenolol Atorvastatin Azathioprine Baclofen Bicalutamide Brimonidine Tartrate Solution Budesonide nasal spray Bupropion HCL Bupropion HCL Bupropion HCL SR Bupropion HCL XL Buspirone Buspirone Candesartan Cilexetil Candesartan Cilexetil Candesartan Cilexetil-HCTZ Candesartan Cilexetil-HCTZ Carbidopa / Levodopa SR Carbidopa / Levodopa Carvedilol Celecoxib Celecoxib Celecoxib Cilostazol Citalopram Clonazepam (CS) Clonazepam (CS) Clonidine HCL Clopidogrel Cyclobenzaprine Diazepam (CS) Diclofenac EC Digoxin Digoxin Diltiazem ER (Dilt-CD) Diphenoxylate/Atropine (CS) Divalproex NA DR Divalproex Sod ER Divalproex Sod ER Dorzolamide HCl 2% Solution Dorzolamide/Timolol Solution Doxazosin Mesylate Duloxetine HCL DR Enalapril Maleate Escitalopram Estradiol Eszopiclone (CS) Etodolac Famotidine Fenofibrate Fenofibrate Fenofibrate, micronized Finasteride Flecainide Acetate Fluconazole Fluoxetine Fluticasone nasal spray Folic Acid Furosemide Gabapentin capsule Gabapentin tablet Gemfibrozil Glimepiride Glipizide ER Glipizide Glyburide/Metformin Glyburide Hydralazine Hydrochlorothiazide Hydrocortisone Hydrocortisone Hydroxychloroquine Hydroxyurea Hydroxyzine pamoate or HCL Ibuprofen Ipratropium/Albuterol Solution Irbesartan Irbesartan/HCTZ Isosorbide Mononitrate ER Isosorbide Mononitrate Labetalol HCL Lamotrigine Latanoprost 0.005% Solution Leflunomide Letrozole Available Strengths 20mg 200mg cap, 400mg tab, 800mg tab 70mg (limit: 12 for 90; 24 for 180) 100mg, 300mg 0.25mg, 0.5mg, 1mg, 2mg mg: 10, 25, 50, 75, 100, 150 2.5mg, 5mg, 10mg 5mg, 10mg 25mg, 50mg, 100mg 10mg, 20mg, 40 mg, 80mg 50mg 10mg, 20mg 50mg 0.2%/10ml dropper 8.6g/32mcg 75mg 100mg 100mg, 150mg, 200mg 150mg, 300mg 5mg, 10mg, 15mg 30mg 4mg, 8mg, 16mg 32mg 16/12.5mg 32/12.5mg, 32/25mg 25/100mg, 50/200mg 10/100mg, 25/100mg, 25/250mg 3.125mg, 6.25mg, 12.5mg, 25mg 50mg, 100mg 200mg 400mg 50mg, 100mg 10mg, 20mg, 40mg 0.5mg 1mg, 2mg 0.1mg, 0.2mg, 0.3mg 75mg 5mg, 10mg 2mg, 5mg, 10mg 50mg, 75mg 0.125mg 0.25mg 120mg, 180mg, 240mg, 300mg 2.5/0.025mg 125mg, 250mg, 500mg 250mg 500mg 10ml dropper 2%/0.5% 10ml dropper 1mg, 2mg, 4mg, 8mg 20mg, 30mg, 60mg 2.5mg, 5mg, 10mg, 20mg 5mg, 10mg, 20mg 0.5mg, 1mg, 2 mg 1mg, 2mg, 3mg 200mg, 300mg cap; 400mg, 500mg tab 20mg, 40mg 48mg, 54mg, 160mg 145mg 134mg 5mg 100mg, 150mg 100mg, 200mg 10mg, 20mg, 40mg 50mcg 1mg 20mg, 40mg, 80mg 100mg, 300mg, 400mg 600mg, 800mg 600mg 1mg, 2mg, 4mg 2.5mg, 5mg, 10mg 5mg, 10mg 1.25/250mg, 2.5/500mg, 5/500mg 1.25mg, 2.5mg, 5mg 10mg, 25mg, 50mg 12.5mg cap, 25mg tab, 50mg tab 5mg 10mg 200mg 500mg 25mg, 50mg 400mg, 600mg, 800mg 0.5mg/3.0mg vial 75mg, 150mg, 300mg 150mg/12.5mg, 300mg/12.5mg 30mg, 60mg 120mg 10mg, 20mg 100mg, 200mg, 300mg 25mg, 100mg, 150mg, 200mg 2.5ml dropper 10mg, 20mg 2.5mg 90-Day 180-Day $35 $55 n/a $20 $25 $45 n/a $20 $9 up to 90 tabs n/a $20 n/a $20 $40 $15 n/a $9 $18 $25 $45 $20 for up to 90 tablets $15 n/a $35 $65 $15 per dropper $62 per nasal spray $40 n/a $40 up to 90 tabs n/a $65 n/a $65 n/a $20 n/a $35 n/a $30 for up to 30 tablets $40 for up to 30 tablets $35 for up to 90 tablets $45 for up to 90 tablets $45 $85 $45 $85 n/a $20 $25 for up to 30 capsules $50 for up to 30 capsules $75 for up to 30 capsules $30 $55 $20 n/a $9 up to 90 tabs n/a $10 up to 90 tabs n/a n/a $20 $20 up to 90 tablets $25 n/a $8 up to 90 tabs n/a $25 n/a $45 for up to 90 tablets $20 n/a $40 up to 90 capsules $35 n/a $35 $65 $65 for up to 90 tablets $95 for up to 90 tablets $15 per dropper $15 per dropper $35 for up to 90 tablets $65 N/A n/a $20 $20 n/a n/a $20 N/A $40 up to 90 tabs $40 up to 90 n/a n/a $20 $55 $95 $55 for up to 30 tablets $70 n/a $25 $45 $35 for up to 90 tablets $35 up to 30 tabs $15 n/a $15 per nasal spray n/a $20 $9 $18 $25 up to 270 capsules $45 up to 270 tablets $30 $55 n/a $20 $35 $65 n/a $20 $30 $55 n/a $20 $25 $45 n/a $20 $15 for up to 90 tablets $25 for up to 90 tablets $22 for up to 30 tablets n/a $25 up to 90 caps $25 n/a $20 n/a $25 for up to 90 vials $30 $55 $30 $55 n/a $20 n/a $20 $30 up to 90 tabs n/a $30 $55 $45 (limit 3) n/a $50 n/a $30 $55 Rx Outreach Medication Levetiracetam Levetiracetam Levetiracetam ER Levothyroxine Lisinopril/HCTZ Lisinopril Lithium Carbonate Lithium Carbonate ER Lorazepam (CS) Lorazepam (CS) Losartan Potassium Losartan/HCTZ Lovastatin Meloxicam Metformin HCL ER Metformin HCL Methotrexate Metoprolol Succinate ER Metoprolol Succinate ER Metoprolol Tartrate Mirtazapine Modafinil (CS) Montelukast Sodium Mycophenolate Mofetil Nabumetone Naproxen Sodium Naproxen Nifedipine ER Nortriptyline HCL Omeprazole Ondansetron/Ondansetron ODT Ondansetron/Ondansetron ODT Oxcarbazepine Oxybutynin Oxybutynin Chloride ER Olanzapine Olanzapine Pacerone® (Amiodarone) Pantoprazole Paroxetine HCL Pentoxifylline ER Phenytoin Sodium Pioglitazone HCL Potassium Chloride powder Potassium Chloride ER Potassium Citrate Pramipexole Pravastatin Prednisone ProAir® HFA Propranolol Propranolol HCL ER Quetiapine Fumarate Quetiapine Fumarate Quetiapine Fumarate Quinapril Ramipril Ranitidine Risperidone Ropinirole HCL Sertraline Simvastatin Spironolactone Sumatriptan Succinate Sumatriptan Succinate Sumatriptan Succinate Tacrolimus Tacrolimus Tamoxifen Citrate Tamsulosin Telmisartan Temazepam (CS) Theophylline ER Tizanidine HCL Topiramate Tramadol (CS) Trazodone Trazodone Triamterene/HCTZ Valacyclovir HCl Valacyclovir HCl Valsartan Valsartan Valsartan/HCTZ Venlafaxine Venlafaxine ER Verapamil SR Verapamil Warfarin Ziprasidone Zolpidem Tartrate (CS) Zolpidem ER (CS) Zonisamide Available Strengths 250mg, 500mg 750mg 1000mg 500mg, 750mg mcg: 25/50/75/88/100/112/125/137/150/175/200/300 10/12.5mg, 20/12.5mg, 20/25mg mg: 2.5, 5, 10, 20, 30, 40 300mg 300mg, 450mg 0.5mg 1mg, 2mg 25mg, 50mg, 100mg 50/12.5mg, 100/12.5mg, 100/25mg 10mg, 20mg, 40mg 7.5mg, 15mg 500mg, 750mg 500mg, 850mg, 1000mg 2.5mg 25mg, 50mg, 100mg 200mg 25mg, 50mg, 100mg 15mg, 30mg, 45mg 100mg, 200mg 10mg, 5mg chewable 250mg Cap, 500mg Tab 500mg, 750mg 550mg 250mg, 375mg, 500mg 30mg, 60mg 10mg, 25mg, 50mg, 75mg 10mg, 20mg, 40mg 4mg 8mg 150mg, 300mg, 600mg 5mg 5mg, 10mg, 15mg 2.5mg, 5mg, 7.5mg, 10mg 15mg, 20mg 100mg, 200mg, 400mg 20mg, 40mg 10mg, 20mg, 30mg, 40mg 400mg 100mg 15mg, 30mg, 45mg 20mEQ, 25mEQ 8mEQ, 10mEQ, 20mEQ 5mEQ, 10mEQ 0.125mg, 0.25mg, 0.5mg, 1mg, 1.5mg 10mg, 20mg, 40mg, 80mg mg: 1, 2.5, 5, 10, 20, 50 8.5g (200 actuations) 10mg, 20mg, 40mg, 80mg 60mg, 80mg, 120mg, 160mg 25mg, 50mg, 100mg 200mg, 300mg 400mg 5mg, 10mg, 20mg, 40mg 1.25mg, 2.5mg, 5mg, 10mg 150mg, 300mg mg: 0.25, 0.5, 1, 2, 3, 4 0.25mg, 0.5mg, 1mg, 2mg 25mg, 50mg, 100mg 5mg, 10mg, 20mg, 40mg, 80mg 25mg 25mg 50mg 100mg 0.5mg 1mg 10mg, 20mg 0.4mg 20mg, 40mg, 80mg 15mg, 30mg 100mg, 200mg, 300mg 2mg, 4mg 25mg, 50mg, 100mg, 200mg 50mg 50mg 100mg, 150mg Cap: 37.5/25mg - Tab: 37.5/25mg, 75/50mg 500mg 1gm 40mg, 80mg 160mg, 320mg mg: 80/12.5, 160/12.5, 160/25, 320/12.5. 320/25 mg: 25, 37.5, 50, 75, 100 37.5mg, 75mg, 150mg 120mg, 180mg, 240mg 40mg, 80mg, 120mg mg: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 20mg, 40mg, 60mg, 80mg 5mg, 10mg 6.25mg, 12.5mg 25mg, 50mg, 100mg 90-Day 180-Day $50 $95 $20 for up to 90 tablets $80 up to 180 tablets n/a $20 $9 $18 $9 $18 $10 up to 270 caps n/a $35 n/a $25 n/a $30 n/a $25 $45 $25 $45 $9 $18 $20 n/a n/a $20 n/a $20 $20 per 12 tabs n/a $35 $65 $45 $85 n/a $20 $30 n/a $80 n/a $40 up to 90 tablets $65 up to 180 units $40 n/a $25 n/a $20 n/a $50 $95 $20 n/a $35 $65 $50 up to 135 tabs n/a $50 up to 90 tabs n/a $60 n/a n/a $20 $45 $85 $25 up to 90 tabs n/a $50 up to 90 tabs n/a $25 $45 $20 n/a $20 n/a $30 $55 $20 up to 180 capsules $25 n/a $40 up to 90 packets $25 up to 90 tablets $15 up to 90 tablets $25 up to 180 tablets $25 up to 90 tablets $20 n/a $35 per canister n/a $20 $45 for up to 90 capsules $25 up to 90 tabs n/a $40 up to 90 tabs n/a $50 up to 90 tabs n/a $30 $55 $25 $45 n/a $20 $45 n/a $45 $85 $25 n/a $25 $45 n/a $20 $35 up to 72 tabs n/a $35 up to 54 tabs n/a $35 up to 27 tabs n/a $60 for up to 90 capsules $75 for up to 90 capsules $25 $45 $30 $55 $35 $65 $16 up to 90 caps n/a $20 up to 90 tablets $55 n/a $35 $65 $7 up to 90 tabs n/a $12 n/a $14 n/a n/a $20 $50 for up to 90 tablets $75 for up to 90 tablets $30 for up to 90 tablets $40 for up to 90 tablets $35 $65 $45 n/a $45 n/a $35 $65 n/a $20 $25 n/a $65 for 90 caps n/a $30 n/a $45 up to 30 tabs n/a $20 up to 90 capsules (CS) Controlled Substance All prescriptions are evaluated by a pharmacist before being filled. The quantity may be limited based on dose restrictions set by therapeutic guidelines and state regulations. PLEASE VISIT OUR WEBSITE TO SEE OUR COMPLETE DRUG LIST Rx Outreach / P. O. Box 66536 / St. Louis, MO 63166-6536 / (888) RXO-1234 / www.rxoutreach.org Rev. 04/15