Home Delivery Order Form

Patient Last Name

Patient First Name

Home Delivery Order Options

Ask your doctor to write your prescription for up to a 90-day supply or the maximum days allowed by your plan

with refills up to one year, if appropriate.

ePrescribe: For fastest service ask your doctor to submit prescriptions electronically to Express Scripts Pharmacy

Online/Mobile App: Log in to myCigna.com or the myCigna® mobile app to refill your medications. You'll be

automatically directed to Express Scripts Pharmacy website where you can choose the medication you want delivered, add

it to your cart, then check out.

Fax: Have your doctor call 888.327.9791 for faxing instructions. (Faxes can only be accepted from a doctor’s office.)

Phone: Call 800.835.3784 for assistance in switching to home delivery.

Mail: Complete the order form and send to Express Scripts Pharmacy along with prescriptions and payment.

Please use ALL CAPITAL LETTERS with black or blue ink. Fill in the ovals as shown. ( )

Member Information

Member ID Number Group #

Member Last Name Member First Name

Please send email notices regarding this order’s status Email address

To go paperless, go to Pharmacy section of myCigna.com and update your Communication Preference under Account.

Shipping Address

Permanent

Temporary

If temporary address, please provide effective dates

From____/____/____ To ____/___/_____

Shipping Address Line 1 (Street address is preferred over PO Box) Apt#

Shipping Address Line 2

City State Zip

Primary Phone Number Circle One

( ) M H W

Secondary Phone Number

Circle One

( )

M H W

Shipping Method

(Expedited shipping will not rush prescription processing)

Standard Free Arrives within 5-10 days after order is shipped

Two Day $12.00 Arrives 2 business days after order is shipped

One Day $21.00

Arrives 1 business day after order is shipped

Patient Information

Please only include prescriptions for patients covered under the above Member ID

Patient #1

Patient Last Name Patient First Name

Patient DOB Gender Male Female

Physician Name Physician Phone

( )

Patient #2

Patient Last Name Patient First Name

Patient DOB Gender Male Female

Physician Name Physician Phone

( )

STLCGNWB

4 Payment Method

Do not send cash

You authorize us to retain on file your payment card details that you used to make this purchase and to charge your payment card

account to pay for any prescription orders requested by you. Should you also choose to enroll in the auto-pay program, you further

consent that we may charge your enrolled payment method for prescription orders made by covered members, including previously

ordered prescriptions which are unpaid.

• We will notify you of any changes to this authorization by email or mail as applicable.

This Card on File Authorization, and if

applicable auto-pay enrollment, will remain in effect until you cancel the authorization by logging into your account or calling the

toll-free number on yo

ur Cigna ID card

. The transaction amount is determined by your plan’s benefit structure at the time th

prescription is

shipped.

• State law prohibits the return

of prescription medications for

resale or reuse. If

you feel a credit or refund is warranted, please

call the number on your prescri

ption label.

• See our privacy policy for information regarding our use and disclosure of personally identifiable information.

Signature X

____________________________________________________________

Cre

dit Card: We accept VISA, MC,

Discover, AMEX, Diners

Automatic, ongoing payment through credit card

Authorize to pay for this order and all future orders with the

credit card below.

For this order only. Simply fill in your credit card

information below.

Credit Card Number

______________________________________

___

Exp Date

______________

Check or Checking Account

Automatic, ongoing payment through checking account

I authorize to

pay for this order and all future orders with the checking

account information below or include a voided check.

For this order only. E

nclose a check payable to Express Scripts

Pharmacy. Write invoice number on the check.

Name of checking account holder

____________________________________

________

Checking Account Number

________________________

____________________

Routing Number (first 9 digits

lower-left corn

er of personal

check)

____________________________________________

Visit myCigna.com to access the Express Scripts Pharmacy website for account balances and t

o make payments. To change the

limit of the amount we can charge your card without a call to you:

• Go to the Pharmacy section of myCigna.com.

• Select Payment

Methods under Account then Edit Information.

• Change the payment authorization limit

You can manage account preferences on the Express Scripts Pharmacy website, accessed through MyCigna.com or call 800.835.3784.

5 Health History

To update your allergies or health conditions: Visit the Express Scripts Pharmacy website by logging into the Pharmacy section of

myCigna.com or call 877.438.4417. This information helps us protect you against potentially harmful drug interactions and allergies.

6 Important reminders and other information

If you are a Medicare Part B beneficiary AND have private health insurance, check your prescription drug benefit materials to

determine the best way to get Medicare Part B drugs and supplies. Or, call Member Services at the toll-free number found on your

ID card. To verify Medicare Part B prescription coverage, call Medicare at 1.800.633.4227.

For additional information or help, visit us at myCigna.com or call us at the toll-free number found on your ID card. TTY/TDD dial

711 and follow the prompts.

Prescriptions may be processed by: Cigna Home Delivery Pharmacy (Tel-Drug, Inc. or Tel-Drug of Pennsylvania, LLC), Express Scripts

Pharmacy (ESI Mail Pharmacy Service, Inc., Express Scripts Pharmacy, Inc. or MAH Pharmacy LLC.), Accredo (Accredo Health Group,

Inc.) or Freedom Fertility Pharmacy (Lynnfield Drug, Inc.).

7 Generic Substitution

State law permits a pharmacist to substitute a less expensive generic equivalent drug for a brand-name drug unless you or your

physician directs otherwise. Please note that this applies to new prescriptions and to any future refills of that prescription. Also be

aware that you may pay more for a brand-name drug.

I do not wish to receive a less expensive brand or generic medication. If the prescription is being submitted electronically, discuss

with your doctor.

Pharmacy services are provided exclusively by or through operating subsidiaries of Cigna Corporation. All trademarks are the property

of their respective owners.

Place your prescription(s), order form(s)

and your payment in an envelope.

Do not use staples or paper clips.

Do not affix po

st it notes to form.

EXPRESS SCRIPTS PHARMACY

PO BOX 66301

ST LOUIS, MO 63166-6301