Mail this form to: Number of New prescriptions: Number of Refill prescriptions: New Prescriptions - Mail your new prescriptions with this form. Refills - Order by Web, phone, or write in Rx number(s) below. Refills. To order mail service refills, enter your prescription number(s) here. A B Apt./Suite # City State ZIP Code Daytime Phone #: Evening Phone #: Last Name First Name MI Suffix (JR, SR) 1) 2) 3) 4) 5) 6) 7) 8) Prescription Plan Sponsor or Company Name Member ID # (if not shown or if different from above) Street Address Please use blue or black ink and print in capital letters. Fill in both sides of this form. Instructions: Use shipping address for this order only. Shipping Address. To ship to an address different from the one printed above, enter the changes here. We may package all of these prescriptions together unless you tell us not to. All claims for prescriptions submitted to CVS Caremark Mail Service Pharmacy using this form ZLOOEHVXEPLWWHGWR\RXUSUHVFULSWLRQEHQHWSODQIRUSD\PHQW,I\RXGRQRWZDQWWKHPVXEPLWWHG to your plan, do not use this form. You may call Customer Care to make alternate arrangements for submission of your order and payment. 2020 CVS Caremark. All rights reserved. P13-N Mail Service Order Form CVS Caremark wants to provide you with high quality medicines at the best possible price. In order to do this, we will substitute equivalent generic medicines for brand name medicines whenever possible. If you do not want XVWRVXEVWLWXWHJHQHULFVSOHDVHSURYLGHVSHFLFLQVWUXFWLRQVLQFOXGLQJGUXJQDPHVLQWKH Special Instructions section of this form. CaremarkPCS Health, LLC (CVS Caremark) is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Blue Cross Blue Shield of Massachusetts. CVS Caremark is part of the CVS Health family of companies. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. TO RECEIVE YOUR ORDER SOONER request refills or new prescriptions online at bluecrossma.org . Go to 90-Day Mail Service under My Medications . CVS Caremark PO BOX 659541 SAN ANTONIO, TX 78265-9541 USVUUVTTVVTUUUVUUVUUVTTUUUTSUUSTSUUSSVUUTTVUVSUVTVSVUVSUSTUSUSTUV