Article Structure
The Aetna Order Form is a streamlined tool designed to facilitate the process of obtaining medications from Aetna Rx Home Delivery®. For first-time customers, it requires completing specific sections to ensure accurate prescriptions and billing information. Sections A, B, and C gather essential details about the patient, their medications, and the preferred method of payment. Returning customers can also utilize the form for new prescriptions or refills and are instructed to make updates only when necessary. Customers must include their member information, along with their mailing and shipping addresses, and each prescription needs to clearly display the member's name, date of birth, and ID. It's important to note that Aetna automatically substitutes generic medications when available, unless specifically requested otherwise. Different methods of delivery, including standard and rush options, are also outlined, along with payment instructions. The form emphasizes the importance of accurate insurance information and provides alternative payment methods, including the option for customers to use Flexible Spending Account (FSA) or Health Savings Account (HSA) cards. Finally, a section is dedicated to capturing family health information to reduce potential drug interactions, thereby enhancing safety in medication delivery. This form acts as a crucial entry point for accessing Aetna’s pharmaceutical services, streamlining the user's experience while ensuring compliance with necessary regulations.
Aetna Order Example
Order Form
Simply follow these easy steps to start using Aetna Rx Home Delivery®:
First Time Customers New Prescriptions
1.Complete Sections A, B and C of the Order Form.
2.Complete the Patient Registration Form.
3.Mail the Order Form and Patient Registration Form with your prescription(s) and method of payment to us. Please print your name, address, date of birth and member ID on each prescription.
Please mail all orders to:
Aetna Rx Home Delivery
P.O. Box 829518
Pembroke Pines, FL
Returning Customers New Prescriptions or Refills of existing prescriptions
1.Complete Sections A, B and C of the Order Form.
2.Complete the Patient Registration Form ONLY if your member information has changed.
3.Mail the Order Form and Patient Registration Form with your prescription(s)
and method of payment to us. Please print your name, address, date of birth and
member ID on each prescription.
Refill orders can also be placed by visiting www.aetna.com/aetnarxhomedelivery
or by calling
Method of Delivery: ❏ Standard ❏ Rush (additional charges apply)
SECTION A
Your Name |
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Date of Birth |
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Your Aetna Member ID |
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Medicare Part B# (if you have one) |
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Home Address |
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City |
State |
ZIP |
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Check here if home address is new |
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Day Phone |
Evening Phone |
Cell Phone |
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Shipping Address (If different than home address) Please note: Address information entered here will only be used for this order.
Name |
Address |
City |
State |
ZIP |
SECTION B
Name
Aetna Member ID
Medication Name and Strength
Prescribing Physician Name and Phone Number
Brand Only If Ordering a Refill: Enter
(X)Refill Numbers Below
We will automatically substitute
In most instances, we are unable to provide refunds for returned medications. If you have questions about your order or our return policy, please call Customer Service at
SECTION C
To estimate the cost of your medications, visit www.aetna.com and log in to AetnaNavigator™. Look for the “Take Action on Your Health” tab, then select “Cost of Care.” The cost of your medication can be found on the “Prescription Drugs” link. You may also call the
Method of Payment: Make a check or money order payable to Aetna Rx Home Delivery or use your personal credit or debit card. Please do not send cash. Important Information:
■If you do not include a method of payment with your order and a previous order was paid for by credit or debit card, we will use that credit or debit card as the method of payment on this order.
■If you have an unpaid balance with our pharmacy this order may not be processed until payment is received.
■If you have a Flexible Spending Account (FSA)
■If you are enrolled in an FSA, Health Savings Account (HSA) or Vital Savings on Health program and have a FSA/HSA/Vital Savings on Health debit card, you can use your card for payment (please also provide a personal credit or debit card to cover any expenses in excess of your account balance).
■Providing a credit or debit card will help prevent delays in order processing that result from insufficient payment.
MC/VISA/AmEx/Discover or debit card number |
Expiration Date |
FSA/HSA debit card number |
Expiration Date |
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Cardholder Name |
Signature |
The credit and/or debit cards used in processing this order will be billed for medication order costs, rush shipping costs (if applicable) and any outstanding balances. They will also be billed for all future orders unless you provide a different form of payment.
Total amount enclosed (if paying by check or money order)
Fill out thefollowing section if this is your first order with Aetna Rx Home Delivery or if this information has changed.
Please complete the following for EACH family member covered under your Aetna pharmacy benefit. Select “None” for family members with no allergies or health conditions. For your convenience, this information will be included as part of your family’s profile with Aetna Rx Home Delivery. We will use this information to check for potential drug interactions and allergies to medications.
For the fields below, mark with an (X) unless otherwise noted.
Member Information
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Allergies |
Health Conditions |
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FAMILY MEMBER NAME
Spanish preferred*
Date Of Birth |
(MM/DD/YYYY) |
Gender (M/F)
Relationship to Subscriber (S)pouse, (C)hild, (O)ther
None
Penicillin
Sulfa
Aspirin
Thyroid
Diabetes
Glaucoma
Heart Conditions
High Blood Pressure
Ulcer
Epilepsy
FAMILY MEMBER NAME
Other allergies or health conditions not listed above (please specify)
If you or a family member has diabetes, indicate the type of supplies being used below:
Name
Monitor
Lancets
Test Strips
Number of tests per day
If you have secondary insurance through another carrier, check here ❏
Please note: By submitting this form, you authorize the release of all the foregoing information to Aetna Rx Home Delivery, LLC, and its affiliates.
Aetna Rx Home Delivery now offers our customers the ability to make payments over the phone for balances due. If you would like to use this payment option, let our Customer Service Associate know and your bank account will be electronically debited for the balance due. The first time you use this service, our Associate will ask you to verify your name, address and some additional information to help us uniquely identify you and secure your transaction. You will then be asked to select a User ID and authorization number, which will be required for future “check by phone” transactions.
When you provide a check as payment, you authorize us to use information from your check either to make a
Please note Aetna Rx Home Delivery's standard shipping practice is to send all medication orders on an account to the health plan subscriber. For example, a family member's order will be sent to the subscriber's address. If you wish to make alternative shipping arrangements please call Customer Service.
*For your convenience, Aetna Rx Home Delivery maintains a staff of
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S5810_7D_50931 (1/2006) |
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©2008 Aetna Inc. |
Form Characteristics
| Fact Name | Details |
|---|---|
| First Time Customer Requirements | Complete Sections A, B, and C of the Order Form and the Patient Registration Form before mailing them with prescriptions and payment. |
| Returning Customer Process | Returning customers need to complete Sections A, B, and C of the Order Form. The Patient Registration Form is only necessary if member information has changed. |
| Mailing Address | All orders must be mailed to: Aetna Rx Home Delivery, P.O. Box 829518, Pembroke Pines, FL 33082-9913. |
| Method of Payment | Payments can be made via check, money order, or credit/debit card. Cash should not be sent. |
| Medication Cost Estimation | Customers can estimate the cost of medications by visiting the Aetna website and navigating to the “Cost of Care” section. |
| Generic Medication Substitution | Generic medications will be substituted for brand-name ones when available, unless specified otherwise by the member. |
| Shipping Options | Standard and rush shipping options are available, with additional charges for rush delivery. |
| Customer Service Contact | For questions or assistance, customers can call Customer Service at 1-800-227-5720. |
Guidelines on Utilizing Aetna Order
Filling out the Aetna Order Form is a straightforward process designed to help you get your prescriptions delivered efficiently to your home. The following steps will guide you through the necessary actions to complete the form correctly. Ensure all information is accurate to avoid delays in processing your order.
- Complete Sections A, B, and C of the Order Form.
- If you’re a first-time customer, fill out the Patient Registration Form.
- Gather your prescription(s) and prepare your method of payment.
- Print your name, address, date of birth, and member ID on each prescription.
- Mail the Order Form, Patient Registration Form, prescription(s), and payment to:
- Aetna Rx Home Delivery
- P.O. Box 829518
- Pembroke Pines, FL 33082-9913
- For returning customers, only fill out the Patient Registration Form if your member information has changed.
- If you are placing refill orders, consider using the website www.aetna.com/aetnarxhomedelivery or call 1-800-227-5720.
For your choice of delivery, indicate if you prefer Standard or Rush service, noting that additional charges apply for the latter. Upon completion, your order will be processed, and you will receive your medications as directed.
What You Should Know About This Form
What steps do I need to follow to place a new prescription order with Aetna Rx Home Delivery?
To place a new prescription order, complete Sections A, B, and C of the Aetna Order Form. Additionally, fill out the Patient Registration Form. Then, mail both forms, along with your prescriptions and payment method, to Aetna Rx Home Delivery at the address provided on the form. Ensure that each prescription includes your name, address, date of birth, and member ID for accurate processing.
What if I am a returning customer and need a refill or new prescription?
If you are a returning customer, complete Sections A, B, and C of the Order Form again. Only fill out the Patient Registration Form if your member information has changed. Mail the completed forms along with your prescriptions and method of payment. For added convenience, refills can also be requested online or over the phone using the provided numbers.
How do I submit payment for my order?
You can submit payment by check or money order made payable to Aetna Rx Home Delivery, or you may use a personal credit or debit card. Do not send cash. If your previous order was paid with a credit or debit card and you do not include a new payment method, Aetna will use the same card for this order.
Can I choose my method of delivery for my medications?
Yes, during the order process, you can select your preferred method of delivery. Options include standard delivery or rush delivery, the latter of which may incur additional charges.
What should I do if I want a brand-name medication instead of a generic?
If you prefer a brand-name medication instead of a generic equivalent, check the “Brand Only” box on the Order Form. Keep in mind that choosing a brand-name drug when a generic is available may result in a higher copay.
How can I find out the cost of my medications?
To estimate the cost of your medications, visit Aetna's website and log in to AetnaNavigator™. Look for the “Cost of Care” section, where you can find pricing details for prescription drugs. You can also call the toll-free number on your Aetna member ID card for assistance.
Are there any limitations on returning medications?
In most cases, Aetna Rx Home Delivery is unable to offer refunds for medications that have been returned. If you have any questions regarding your order or the return policy, contact Customer Service for assistance.
What if I have additional family members who need medications through Aetna?
If you have family members covered under your Aetna pharmacy benefit, ensure you complete the Order Form for each member. Provide their information, including any allergies or health conditions, so Aetna can check for potential drug interactions and maintain accurate records.
Common mistakes
People often make mistakes when filling out the Aetna Order form, which can delay their medication orders. One common error is not completing all necessary sections. Sections A, B, and C are essential for both new prescriptions and refills. Failing to fill in any of these sections can lead to processing issues. It’s important to take the time to ensure every part is filled out correctly.
Another mistake occurs when patients neglect to include the necessary patient information. Each prescription must have the patient's name, address, date of birth, and member ID clearly printed. If any of this information is missing or incorrect, it can cause confusion and result in delays in receiving the medications. Make sure to double-check these details before submission.
Some individuals forget to provide a method of payment or fail to sign the form. The form specifically states to include a check or provide credit card information, depending on preference. Not including this vital information can lead to automatic re-routing of payments, which may not always work in the customer’s favor. Additionally, a missing signature can halt processing altogether.
Lastly, people sometimes overlook the shipping address section. If a different address is used for shipping, it needs to be clearly indicated. Not checking this section can lead to orders being sent to the wrong location. To ensure the order arrives on time, clarity about the shipping address is crucial. Always verify that you're sending it to the right place.
Documents used along the form
The Aetna Order Form is a key document for both new and returning customers looking to utilize Aetna Rx Home Delivery services. Several other forms and documents complement this order process, ensuring that all necessary information is collected for effective prescription management. Below is a list of documents typically used alongside the Aetna Order Form.
- Patient Registration Form: This form collects the personal details of the patient, including name, address, and insurance information. It’s essential for establishing a patient's profile in the Aetna system.
- Prescription Documentation: Any valid prescription from a licensed healthcare provider must be included. This document authorizes Aetna to dispense the specified medication to the patient.
- Payment Authorization Form: If using electronic payments, this form allows Aetna to charge the provided credit or debit card for prescription costs and shipping fees.
- Medication History Form: This document provides Aetna with information about previously used medications. It helps in avoiding potential drug interactions.
- Insurance Verification Form: This form confirms coverage and benefits through Aetna. It ensures all prescriptions align with the patient’s current insurance plan.
- Medication Refill Request Form: For existing prescriptions, this form helps in requesting refills more efficiently. It streamlines the process for both the patient and Aetna.
- Authorization for Release of Medical Information: This document allows Aetna to obtain necessary medical records from healthcare providers for prescription validation and safety checks.
- Family Member Medical Information Form: It collects health data on family members who may also be under Aetna’s coverage. This is crucial for identifying shared health conditions that may affect prescription choices.
- Shipping Information Form: This form captures alternative shipping addresses. It is particularly useful when patients want their medications sent to different locations.
- Feedback Form: After receiving services, patients can fill this out to share their experiences, helping Aetna improve their delivery and service processes.
Using these forms in conjunction with the Aetna Order Form creates a comprehensive approach to managing prescription needs. Each document plays a critical role in ensuring accuracy and efficiency in service delivery.
Similar forms
- Prescription Drug Refill Request Form: This document requires similar personal and prescription information as the Aetna Order Form. Both forms ask for details about the patient, including name, Aetna member ID, and medication details. They also emphasize the importance of including accurate payer information to prevent processing delays.
- Patient Registration Form: Like the Aetna Order Form, this form collects vital information about the patient, such as contact details and member ID. Both forms streamline the process of medication orders by ensuring the provider has necessary patient information to fill prescriptions efficiently.
- Medication Delivery Preference Form: This form, similar to the Aetna Order Form, allows users to specify their preferred method of medication delivery. Both documents prioritize patient choice and ensure that delivery addresses are verified to avoid errors.
- Flexible Spending Account (FSA) Request Form: This document requires payment method information, paralleling the Aetna Order Form’s method of payment section. Both forms necessitate information on how to cover medication expenses while adhering to necessary account rules and conditions.
Dos and Don'ts
When filling out the Aetna Order form, it is important to ensure that all information is accurate and complete. Here’s a list of what you should and shouldn’t do:
- Do complete Sections A, B, and C accurately, providing all required personal information.
- Do print your name, address, date of birth, and member ID on each prescription.
- Do use a credit or debit card for payment to prevent delays in processing.
- Do submit the Patient Registration Form if any of your member information has changed.
- Do check off the “Brand Only” option for medications if you specifically want brand-name drugs.
- Don’t send cash with your order; only checks, money orders, or cards are accepted.
- Don’t forget to include a method of payment; otherwise, a previous payment method may be used without your consent.
- Don’t ignore any outstanding balance on your account, as this may prevent your order from being processed.
- Don’t leave out your shipping address if it differs from your home address; this may lead to delivery issues.
- Don’t disregard the importance of accurate allergy and health condition information, as this can affect your treatment.
Misconceptions
- Misconception 1: You can skip sections of the order form.
- Misconception 2: It’s unnecessary to include personal information on each prescription.
- Misconception 3: You cannot order refills online.
- Misconception 4: All orders will automatically be processed regardless of payment method.
- Misconception 5: You must pay by check or money order.
- Misconception 6: Generic drugs are not offered.
- Misconception 7: You can’t change the shipping address.
- Misconception 8: Orders are shipped immediately after they are submitted.
- Misconception 9: Aetna Rx Home Delivery supports only English-speaking customers.
All sections A, B, and C of the order form must be completed to ensure accurate processing of your prescription.
It is crucial to print your name, address, date of birth, and member ID on each prescription to avoid any delays.
Returning customers can easily place refill orders online at www.aetna.com/aetnarxhomedelivery or by calling the provided customer service number.
If a method of payment is not included, previous payment methods will be used if applicable, but orders may be held if you have an unpaid balance.
You can also use a credit or debit card for payment, which can expedite the order process.
Aetna automatically substitutes FDA-approved generic medications unless you specify "Brand Only" on your order form.
You may provide a different shipping address, but it will be used only for the current order unless specified otherwise.
Processing and shipping times can vary based on payment method, prescription requirements, and existing balances.
Aetna Rx Home Delivery offers assistance from Spanish-speaking representatives for those who prefer communication in Spanish.
Key takeaways
When using the Aetna Order Form, it is important to accurately complete Sections A, B, and C to ensure that all necessary information for processing your prescription is included.
New customers must also fill out the Patient Registration Form, while returning customers should only do so if their member information has changed.
Be sure to provide a method of payment with your order. Acceptable payment methods include checks, money orders, or credit/debit cards. Cash is not accepted.
If you have questions about your order or need assistance, reach out to Customer Service at 1-800-227-5720. They are available to help clarify any aspects of the order process.
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