Get started on home delivery
by choosing from two easy options
Option 1
Call Prescription Solutions.
Call 1-877-889-5802 (TTY 711), 24 hours a day, 7 days a week. Please have your current
prescription label with you when you call.
Option 2
Talk to your physician.
Explain to your physician that you would like to receive home delivery of your maintenance
medication(s)1 through Prescription Solutions. Ask for a new 90-day prescription (with three refills)
to maximize your plan benefits. Then you can either:
Mail your written prescription with the enclosed order form.
Or ask your physician to call 1-800-791-7658 (TTY 711), with your prescriptions,
8 a.m. – 8 p.m. CT, Monday-Friday, excluding certain holidays, or fax them to
1-800-491-7997, 24 hours, 7 days a week.
For more information about Prescription Solutions, visit www.AARPMedicareRx.com/Mail.
Maintenance medications are typically those drugs you take on a regular basis for a chronic or
long-term condition.
1
These Medicare Prescription Drug Plan(s) (PDP(s) are insured by UnitedHealthcare Insurance
Company or UnitedHealthcare Insurance Company of New York for New York residents (together called
“UnitedHealthcare”). AARP® MedicareRx Plans carry the AARP name, and UnitedHealthcare pays a royalty
fee to AARP for use of the AARP intellectual property. Amounts paid are used for the general purpose of
AARP and its members. AARP is not the insurer. UnitedHealthcare contracts with the Federal government
as a Medicare-approved Part D sponsor. All decisions about prescription drugs are between you and your
physician or other health care provider.
PDP3274952_000
Y0066_PDP3274952_000 File & Use 11222010
Client & Agency Team
Project Details
Timeline
Specs
Client Supervisor: Trish Adams
Project Name: Web Fill-In Order Form - AARP Rx
Date Assigned: 8/23/10
Colors: 3/1 ( PMS 485, 072, K )
TA Manager: Chase Oborn
File Name: 2011_Web_Fill-In_Order_Form_PDP3274952_000_AARP-Rx_TA8751_R9_1220.indd
Date Due: 12/20/10
Dimensions: 8.5” x 11”
TA Creative: Deril Johnson
TA Job Number: TA8751
Stage: FINAL
Format: Form
TA Production:
Code: PDP3274952_000
Revision: R10
Software: Adobe InDesign CS3
Notes
New Prescription Mail-In Form
1
Fill out and print an order form for each member. Please write the member ID and date of birth on
each original prescription and mail with the completed order form(s). DO NOT STAPLE OR TAPE
PRESCRIPTIONS TO THE ORDER FORM.
Member ID:
Plan Name:
Last Name
First Name
MI
Delivery Address
Apt. #
City
State
Date of Birth (mm/dd/yyyy)
/
/
Gender
M
2
ZIP
F
Phone Number
(
)
Email
Health History — please check all that apply.
If you are a new customer or your allergies or health conditions have changed, please indicate all that apply. The information
you provide will allow a more complete review of your current medication request.
Medication Allergies:
None
Amoxicillin/Ampicillin
Aspirin
Cephalosporins (e.g. Cephalexin)
Health Conditions:
None
Allergies — Seasonal
Arthritis
Codeine
Erythromycin
NSAIDs (e.g. Ibuprofen)
Penicillin
Quinolones (e.g. Ciprofloxacin)
Asthma
Cancer
Diabetes
Glaucoma
Sulfa Medications
Tetracyclines
Other (please specify)
Heart Condition
High Blood Pressure
High Cholesterol
Thyroid Disease
Other (please specify)
Please list any over-the-counter or herbal medications you take regularly:
3
Generic Substitution
FDA-approved generic equivalents will be dispensed for brand-name medications whenever possible, unless you or your
physician indicate otherwise. If you require brand-name medications, please list those medications in the Notes to Pharmacy
section below with a brand-name only notation. Note: brand-name medications may be subject to a higher cost.
Notes to Pharmacy:
4
Payment and Shipping Information — do not send cash.
Standard delivery is at no charge. Most orders arrive about 7 days from the date your completed order is received. If clarification
of your order is required, delivery may take longer. If you would like overnight shipping, please indicate below. Please note that
expedited shipping only affects shipping time, not the processing time of your order.
Ship overnight. Add $12.50 to order amount (subject to change).
Check enclosed. All checks must be signed and made payable to Prescription Solutions.
Charge to my credit card on file. Visa, MasterCard®, American Express®, and Discover cards are accepted.
Charge to my NEW credit card.
New Credit Card Number
Expiration Date (Month/Year)
/
Signature:
Date:
This credit card will be billed for applicable medications, overnight shipping and outstanding balances. I authorize Prescription Solutions to maintain my
credit card on file as payment method for any future charges or outstanding balances. To modify payment selection, please contact Customer Service.
Prescription Solutions, P.O. Box 2975, Mission, KS 66201-1375
PS2438 Rev 12/10
Client & Agency Team
Project Details
Timeline
Specs
Client Supervisor: Trish Adams
Project Name: Order Form – NON-BRM Kansas
Date Assigned: 8/03/10
Colors: 1/0 (Black)
TA Manager: Chase Oborn
File Name: Order_Form_KS_NON-BRM_PS2438-Rev-12-10_TA6906_R2_1210.indd Date Due: 12/10/10
Dimensions: 8.5” x 11”
TA Creative: Deril Johnson
TA Job Number: TA6906
Stage: Client Review
Format: Form
TA Production:
Code: PS2438 Rev 12/10
Revision: R2
Software: Adobe InDesign CS3
Notes