New Prescription Mail-In Order Form
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Member and physician information — please use black or blue ink. One form per member.
Gender
Member ID Number
Last Name
First Name
Apt. #
City
State
/
Phone Number (list in order of preference)
ZIP
(circle one)
(_____)____________________ M H W
Email
/
(_____)____________________ M H W
Physician Phone Number
(
)
Physician Name
2
F
MI
Delivery Address
Date of Birth
M
(
)
M H W
Health history
Medication Allergies:
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Amoxil/Ampicillin
Aspirin
Cephalosporins
Codeine

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
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Erythromycin
NSAIDs
Penicillin
Quinolones

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Health Conditions:
None Known
Sulfa
Tetracyclines
Others:
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Arthritis
Asthma
Cancer
Diabetes

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List all prescription, over-the-counter and herbal medications taken regularly:
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Glaucoma
Heart Condition
High Blood Pressure
High Cholesterol
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None Known
Osteoporosis
Thyroid Disease
Others:
(use additional sheet if necessary)
Pharmacy processing
Generic substitution. FDA-approved generic equivalents will be dispensed for brand-name drugs whenever possible,
unless you or your physician indicate otherwise. Brand-name medications may be subject to a higher cost.
Keep on file. If you are including any prescriptions that you want to keep on file for shipment at a later date, please list them here:
Notes to Pharmacy:
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Payment and shipping information — do not send cash.
Standard delivery is included at no charge. Most prescription orders arrive within 7 days from the date your order is received. We will
contact you if there is an extended delay in delivering your medications. Please call 866.554.2673 if you have any questions.
Once shipped, medications may not be returned for a refund or adjustment. Log on to www.magellanrx.com to download
additional order forms.
Credit Card Number
Ship overnight. Additional charges will
apply. Please call to verify pricing.
Charge to my NEW credit card.
Visa, MasterCard, AMEX and Discover are accepted.
Charge to my credit card on file.
Keep this card on file.
Expiration Date (Month/Year)
Check enclosed. All checks must be
signed and made payable to: Magellan Rx Management
/
Signature:
Date:
For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance, and other such expenses related to
prescription orders. By supplying my credit card number, I authorize Magellan Rx Management to maintain my credit card on file as payment
method for any future charges . To modify payment selection, Customer Service can be contacted at any time.
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Mail this completed order form with your new prescription(s) to ICORE Healthcare, a part of Magellan Rx Management,
PO Box 621988, Orlando, FL 32862. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.
MRX_1001_1014
GLUE
RETURN ADDRESS
Magellan Rx Management
PO Box 621988
Orlando, FL 32862
at 866.554.2673.
24/7 support is available
4. We’ll call your physician for you. Simply call us at
1.866.554.2673 (TTY/TDD 1.800.424.0328) and be
prepared to provide your medication names and dosages
along with your physician’s name and phone number.
3. Visit www.MagellanRx.com to download a Mail Order Form,
complete it and send it along with your new 90-day
prescription to PO Box 621988 Orlando, FL 32862
2. Your physician can phone us at 1.866.554.2673
(TTY/TDD 1.800.424.0328)
Here are four different ways to get started using home delivery:
1. Your physician can fax your prescriptions to
1.866.364.2673
Taking advantage of your prescription home delivery benefit may
enable you to receive up to a 90-day supply of your maintenance
medication(s) at a discounted price. Just ask your physician to
write you two prescriptions: one for a 30-day supply to get you
started (to be filled at your local pharmacy), and one for a
90-day supply, plus additional refills (to be filled at our home
delivery pharmacy).
Get Started with
Home Delivery
Today!