Fill your prescriptions with home delivery.

How it works.1 Order up to a three-month supply of your maintenance

medications ones you take regularly by mail, phone or online.

2 OptumRx fills your order, mails it to you and lets you know when to expect your delivery.

3 Your medication arrives within 7 to 10 days of placing the order. OptumRx will notify you if there will be a delay in your order.

Four easy ways to enroll:Online.Log in to azblue.com/member. Click on Plan Benefits, and select Mail Order under Pharmacy Benefits.

Phone.Call the Pharmacy Benefits number on the back of your member ID card. For hearing impaired, TTY 711.

Mail.Complete the attached order form and mail it to OptumRx, P.O. Box 509075, San Diego, CA 92150.

ePrescribe.Or your doctor can send an electronic prescription to OptumRx.

The benefits of home delivery.

Save a trip to the pharmacy.

You may pay less for up to a 90-day supply of your maintenance medication.

No charge for standard shipping.

Phone, text1 and email reminders help you remember every dose and every refill.

1. OptumRx provides this service at no additional cost. Standard message and data rates charged by your carrier may apply.

or registered marks of their respective owners.

2017 Optum, Inc. All rights reserved. ORX63255-032017-BCBSAZ

All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks

NRX001

NEW PRESCRIPTION MAIL-IN ORDER FORMMember and physician information please use black or blue ink. One form per member.

Member ID Number

(Additional coverage, if applicable) Secondary Member ID Number

Last Name First Name MI

Delivery Address Apt. #

City State ZIP

Phone Number with Area Code

Date of Birth (mm/dd/yyyy) Gender M F

Email

Physician Name

Physician Phone Number with Area Code

Health historyMedication Allergies: Aspirin Erythromycin Quinolones Others: None known Cephalosporins NSAIDs Sulfa Amoxil/Ampicillin Codeine Penicillin Tetracyclines

Health Conditions: Asthma Glaucoma High cholesterol Others: None known Cancer Heart condition Osteoporosis Arthritis Diabetes High blood pressure Thyroid Disease

Over-the-counter/herbal medications taken regularly:

Payment and shipping information do not send cashStandard delivery is included at no charge. New prescriptions should arrive within about 10 business days from the date the completed order is received. Completed refill orders should arrive within about 7 business days. OptumRx will contact you if there will be an extended delay in delivering your medications.

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 OptumRx to maintain my credit card on file as payment method for any future charges. To modify payment selection, contact customer service at any time.

1

2

3

4

You may log on to optumrx.com to see if drug pricing information is available before enclosing payment. Once shipped, medications may not be returned for a refund or adjustment.

Mail this completed order form with your new prescription(s) to OptumRx, P.O. Box 509075, San Diego, CA 92150. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.

54778-032016 ORX5634_140915

Ship overnight. Add $12.50 to order amount (subject to change).

Check enclosed. All checks must be signed and made payable to: OptumRx.

Charge to my credit card on file. Charge to my NEW credit card.

Signature: Date:

New Credit Card Number

Expiration Date (Month/Year) Visa, MasterCard, AMEX and Discover are accepted.

Nondiscrimination notice and access to communication services

Optum companies (together, Optum) provide services to health plans and other health programs or activities.

Optum does not exclude people or treat them unfairly because of sex, age, race, color, national origin, or disability.

Free services are available to help you communicate with us and with your health plan. Such as, letters in other languages, or in other formats such as large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free number on your member ID card, TTY 711.

If you think you werent treated fairly because of your sex, age, race, color, national origin, or disability, you can send a complaint to:

Optum Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344

Phone: 1-888-445-8745, TTY 711 Fax: 1-855-351-5495 Email: Optum_Civil_Rights@optum.com

If you need help with your complaint, please call the toll-free number on your member ID card, TTY 711. You must send the complaint within 60 days of when you found out about the issue.

You can also file a complaint with the U.S. Dept. of Health and Human services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

U.S. Dept. of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Language Assistance Services & Alternate Formats

This information is available in other formats like large print. To ask for another format, please call the toll-free number on your member ID card, TTY 711.

English:

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