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When it comes to managing prescriptions through Aetna Rx Home Delivery, the Aetna Order Form serves as a vital tool for both new and returning customers. This form empowers users to effectively order medications and manage their prescription needs with ease. For first-time customers, a few straightforward steps are required to complete the process: filling out critical sections of the order form, submitting a patient registration form, and mailing these documents alongside the prescription and payment. Returning customers can expedite their ordering by including any updates to their member information and can also choose to refill existing prescriptions through alternative methods like the Aetna website or a customer service call. The order form itself is divided into different sections, where customers provide their personal details, medication specifics, and payment methods. Additionally, it outlines essential considerations such as the choice between standard and rush delivery options, the implications of selecting brand-name medications, and the necessity for accurate billing information. Overall, this form facilitates a seamless experience, offering clarity and efficiency in managing medication deliveries while emphasizing the importance of thoroughness in completing all required sections. Timely submission of this information not only helps avoid processing delays but also enhances the overall customer experience with Aetna's pharmacy services.

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 33082-9913

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 1-800-227-5720 (TDD: 1-800-823-6373).

Method of Delivery: ❏ Standard ❏ Rush (additional charges apply)

SECTION A

Your Name

 

 

Date of Birth

 

 

 

 

 

 

Your Aetna Member ID

 

 

Medicare Part B# (if you have one)

 

 

 

 

 

 

Home Address

 

City

State

ZIP

 

 

 

 

 

Check here if home address is new

 

 

 

 

 

 

 

 

Day Phone

Evening Phone

Cell Phone

E-mail

 

 

 

 

 

 

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 FDA-approved generic medications for brand-name medications when (1) a generic equivalent medication is available and (2) your doctor’s prescription instructions allow. If you do not want us to substitute a generic, you must check “Brand Only” above for the medication(s) you want dispensed as brand only. If a member chooses a brand-name drug when a generic alternative is available (regardless of the reason), they may be subject to a higher copay.

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 1-800-227-5720.

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 toll-free number on your Aetna member ID card for medication cost information.

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) auto-debit feature, or are enrolled in an Aetna HealthFund® or Vital Savings on HealthSM plan, please provide a personal credit or debit card to cover any expenses that may exceed your account balance.

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

 

 

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)

18.09.308.1-FL WEB (1/08) S5810_7D_50931 (1/2006)

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

Allergies

Health Conditions

 

 

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 one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day [you make] [we receive] your payment[, and you will not receive your check back from your financial institution].

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 Spanish-speaking customer service representatives.

18.09.308.1-FL WEB (1/08)

S5810_7D_50931 (1/2006)

 

©2008 Aetna Inc.

File Breakdown

Fact Name Description
Form Purpose The Aetna Order Form is used for both new prescriptions and refill requests for Aetna Rx Home Delivery®.
First-Time Customers New customers must complete Sections A, B, and C, along with the Patient Registration Form to start their order.
Returning Customers Returning customers only need to complete Sections A, B, and C unless their member information has changed.
Mailing Address All orders should be mailed to Aetna Rx Home Delivery, P.O. Box 829518, Pembroke Pines, FL 33082-9913.
Payment Options Payments can be made via check, money order, or credit/debit card. Cash should not be sent.
Medication Cost To estimate medication costs, customers can visit Aetna's website or call the number on their member ID card.
Generic Substitution Aetna will substitute generic medications for brand-name ones unless "Brand Only" is checked on the order form.
Shipping Methods Customers can choose between standard and rush shipping for their orders, with rush shipping incurring additional charges.
Customer Support For questions about orders or policies, customers can call Aetna's customer service at 1-800-227-5720.
Prescription Details Each prescription must include the customer's name, address, date of birth, and member ID printed clearly.

Guide to Using Aetna Order

Completing the Aetna Order Form is an essential step toward ensuring you receive your medications efficiently. Whether you are a first-time customer or a returning user, following the guidelines will help you through the process. Please read through the steps carefully to ensure all necessary information is provided.

  1. Complete Sections A, B, and C of the Order Form.
  2. If you are a first-time customer, complete the Patient Registration Form.
  3. For returning customers, only fill out the Patient Registration Form if your member information has changed.
  4. Mail the Order Form and Patient Registration Form along with your prescription(s) and your method of payment.
  5. Print your name, address, date of birth, and member ID on each prescription.
  6. Select your method of delivery: Standard or Rush (note that additional charges apply for rush service).
  7. Include a check or money order made out to Aetna Rx Home Delivery, or provide credit or debit card information for payment.
  8. Ensure your total amount is enclosed if paying by check or money order.
  9. Mail all orders to: Aetna Rx Home Delivery, P.O. Box 829518, Pembroke Pines, FL 33082-9913.
  10. If you have questions regarding your order or need assistance, contact Customer Service at 1-800-227-5720.

Get Answers on Aetna Order

What steps do I need to follow to place my first order with Aetna Rx Home Delivery?

To place your first order, complete Sections A, B, and C of the Order Form. Additionally, fill out the Patient Registration Form. It is crucial to mail both forms, along with your prescription(s) and the payment method, to Aetna Rx Home Delivery at the following address:

Aetna Rx Home Delivery
P.O. Box 829518
Pembroke Pines, FL 33082-9913

When mailing your prescriptions, make sure to print your name, address, date of birth, and member ID on each prescription for clarity.

How do returning customers place orders for new prescriptions or refills?

Returning customers should follow a similar process. Complete Sections A, B, and C of the Order Form. If there are changes to your member information, fill out the Patient Registration Form. Send both forms, along with your prescriptions and payment details, to the same address mentioned earlier.

For refills, there is also an option to place your order online at www.aetna.com/aetnarxhomedelivery or by calling 1-800-227-5720.

What payment methods can I use for my order?

You have several options when it comes to payment. You can pay by check or money order made out to Aetna Rx Home Delivery, or you can use a personal credit or debit card. Please avoid sending cash through the mail.

If previous orders were paid using a credit or debit card, Aetna may automatically use that card for your new order if no other payment method is provided. If not, ensure you provide a valid payment method to avoid delays in processing your order.

What if I have additional questions about my order or the return policy?

If you have any questions regarding your order or the return policy, contacting Customer Service is the best option. You can reach them at 1-800-227-5720. They are available to assist you with any concerns you might have about your medications or the ordering process.

Common mistakes

When filling out the Aetna Order Form, many individuals encounter challenges that can lead to errors. Understanding these common mistakes can help ensure a smoother ordering process. One frequent error is neglecting to complete all necessary sections. Specifically, Sections A, B, and C must all be filled out accurately. Missing any of these sections can delay processing.

An additional mistake arises when individuals fail to provide their method of payment. Without a clear indication of how payment will be made, the order may not be processed in a timely manner. A check or money order must be included if paying by mail, and this should be clearly indicated on the form.

Incorrectly entering personal information is another common issue. Members sometimes miswrite their name, address, or member ID, which can complicate both order shipping and verifications. It is essential to double-check this information against your Aetna member ID card to avoid errors.

Moreover, many forget to print their information on each prescription. Including your name, address, date of birth, and member ID on every prescription ensures that orders can be matched to the correct member profile.

Returning customers often make the mistake of not completing the Patient Registration Form when their information has changed. Only fill this out if there has been a change in your member information. Failure to do so may result in processing delays as the Aetna team will not have updated contact or member details.

Another common oversight involves not indicating brand-name preferences. If a member specifies “Brand Only” but fails to check this option, the pharmacy may automatically substitute a generic medication. This could lead to unexpected costs or dissatisfaction with the order.

Additionally, individuals sometimes overlook shipping details. If the shipping address is different from the home address, it must be indicated clearly on the order form. Failing to do this will result in medication being sent to the incorrect location.

Lax attention to the allergy and health condition fields is also a common issue. Accurately disclosing any allergies or existing conditions related to medication is crucial for safety. Missing this information could compromise medical care during the order fulfillment process.

Many customers also make the mistake of not providing a secondary payment method. If there are insufficient funds in the specified account, the order may be delayed. Providing an alternative credit or debit card can help prevent these issues.

Lastly, it is vital to cross-check the expiration dates of payment cards. An expired card can lead to immediate rejection of the payment, causing further delays and potentially affecting access to medications when they are needed most.

Documents used along the form

When utilizing the Aetna Order form for medication delivery, several other documents may accompany it to ensure proper processing and compliance with healthcare requirements. Here is a list of documents that are commonly used alongside the Aetna Order form, each serving its own purpose in the drug order process.

  • Patient Registration Form: This form gathers essential personal information about the patient, such as their address, date of birth, and member ID. It is especially important for new patients or when there have been changes to existing member information.
  • Medication History Form: This document provides a record of past prescription medications, including dosages and dates of prescription. It helps healthcare providers assess current treatments and avoid potential drug interactions.
  • Insurance Information Form: Patients use this form to provide details about their health insurance coverage. It helps to verify coverage for the medications requested and ensures accurate billing.
  • Prescription Labeling Guidelines: These guidelines indicate how medications should be labeled for delivery. They ensure that patients receive clear instructions and specific details regarding their prescriptions, including dosage and administration.
  • Consent to Release Health Information Form: This form obtains the patient's consent to share their medical records and medication information with the pharmacy or other healthcare providers as needed, ensuring continuity of care.
  • Payment Authorization Form: If payment will be automatically deducted from a bank account or charged to a credit card for prescriptions, this form provides authorization. It keeps payment processing straightforward and avoids future complications.
  • Drug Interaction Check List: This form assists patients and pharmacists in identifying potential drug interactions with existing medications. It promotes safety by allowing for a review before new medications are filled.
  • FSA/HSA Payment Form: Patients use this form to indicate if they are utilizing Flexible Spending Accounts (FSA) or Health Savings Accounts (HSA) for medication payment. This documentation is important for smooth financial transactions.

By using these forms and documents in conjunction with the Aetna Order form, patients can facilitate a smoother process for obtaining their prescriptions. Each document plays a critical role in ensuring accurate, safe, and efficient medication delivery, meeting both patient needs and regulatory requirements.

Similar forms

  • Prescription Order Form: Similar to the Aetna Order Form, a prescription order form is used to request medication from a pharmacy. It typically includes sections for patient information, prescription details, and payment methods. Both forms require the prescriber’s information and the patient’s consent for medications.

  • Patient Registration Form: This document captures essential information about the patient, including health insurance details and personal identification. Like the Aetna Order Form, it is crucial in establishing a patient's eligibility for services and managing their health records effectively.

  • Claim Submission Form: A claim submission form allows patients to request reimbursement for medical expenses. It is similar to the Aetna Order Form in that it requires detailed information about the patient, services rendered, and payment methods. Both forms aim to process the submission accurately and ensure timely reimbursement.

  • Medication Administration Record (MAR): This document is used by healthcare providers to record medications administered to patients. It echoes the Aetna Order Form’s focus on medication details and patient instructions, ensuring that proper medication management takes place in a clinical setting.

  • Authorization for Release of Medical Information: This form is necessary for sharing sensitive patient information with third parties. Like the Aetna Order Form, it emphasizes the importance of patient consent and includes specific patient details, ensuring compliance with privacy laws and regulations.

Dos and Don'ts

Here’s a helpful list of things to keep in mind when filling out the Aetna Order form. Following these tips can help ensure a smooth process.

  • Do: Make sure you complete all required sections, specifically Sections A, B, and C.
  • Do: Include your prescription(s) along with the Order Form and Patient Registration Form.
  • Do: Clearly print your name, address, date of birth, and member ID on each prescription.
  • Do: Check the “Brand Only” option if you prefer a brand-name medication over a generic alternative.
  • Do: Use a credit or debit card for quicker payment processing if you're able to.
  • Don't: Forget to include a method of payment; otherwise, your order may face delays.
  • Don't: Send cash; only checks, money orders, or cards are acceptable.
  • Don't: Leave any essential fields blank—they are crucial for proper processing.
  • Don't: Forget to indicate if the shipping address is different from your home address.
  • Don't: Forget to specify any allergies or health conditions relevant to the prescribed medications.

Misconceptions

Understanding the Aetna Order Form can be difficult. Here are seven common misconceptions that people often have:

  1. You need to complete every section for all orders. Many think that every section of the form must be filled for every order. However, only specific sections need to be completed based on whether you are a new or returning customer.
  2. Returning customers don’t have to complete the Patient Registration Form. Some believe that returning customers should not fill out the Patient Registration Form at all. This is only true if there are no changes to member information.
  3. Payment methods are strictly limited. There is a misconception that only checks or credit cards can be used. In reality, you can also use HSA or FSA debit cards, as long as you provide a personal card for any expenses that exceed your account balance.
  4. The address you provide is permanent. Many assume that any shipping address listed will be stored for future orders. In fact, the address entered for your order is only used for that specific shipment.
  5. Refunds are always available if you change your mind. It’s common to think that you can return medications for a full refund. However, Aetna often cannot provide refunds for returned medications.
  6. There are no additional charges for rushed delivery. Some people believe rush delivery is the same as standard delivery. This is incorrect, as added fees apply for rush services.
  7. All orders will automatically have generic medications sent. It is a misconception that Aetna will send generic medications regardless of your preferences. You must indicate if you wish to receive brand-name medications instead.

Understanding these misconceptions can help ensure a smoother experience when using the Aetna Order Form. Always read through the instructions carefully and reach out for assistance when needed.

Key takeaways

Filling out the Aetna Order Form correctly is essential for a smooth order process. Here are five key takeaways to keep in mind:

  • Sections A, B, and C: Always complete these sections on the Order Form whether you are a first-time or returning customer. This ensures that all necessary information is provided.
  • Patient Registration: If your member information has changed, fill out the Patient Registration Form. First-time customers must complete this form for accurate processing.
  • Prescription Information: Include your name, address, date of birth, and member ID on every prescription submitted. This detail helps avoid any confusion.
  • Payment Methods: Acceptable payment methods include checks, money orders, or credit/debit cards. Avoid sending cash, as it may lead to issues.
  • Delivery Options: Choose between standard and rush delivery methods. Be aware that additional charges may apply for rush orders.

Following these guidelines can help ensure your experience with Aetna Rx Home Delivery remains efficient and hassle-free.