® Mail Service Order Form Mail this form to: USVUUVTTVVTUUUVUUVUUVTTUUUTSUUSTSUUSSVUUTTVUVSUVTVSVUVSUSTUSUSTUV CVS Caremark PO BOX 659541 SAN ANTONIO, TX 78265-9541 Member ID # (if not shown or if different from above) Prescription Plan Sponsor or Company Name Instructions: Please use blue or black ink and print in capital letters. Fill in both sides of this form. New Prescriptions - Mail your new prescriptions with this form. Number of New prescriptions: Refills - Order by Web, phone, or write in Rx number(s) below. Number of Refill prescriptions: ORDER SOONER request refills or new prescriptions online at bluecrossma.org. TO RECEIVE YOUR Go to 90-Day Mail Service under My Medications. AShipping Address. To ship to an address different from the one printed above, enter the changes here. Last Name First Name MI Suffix (JR, SR) Street Address Apt./Suite # Use shipping address for this order only. City State ZIP Code Daytime Phone #: Evening Phone #: B Refills. To order mail service refills, enter your prescription number(s) here. 1) 2) 3) 4) 5) 6) 7) 8) 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 XVWRVXEVWLWXWHJHQHULFVSOHDVHSURYLGHVSHFL¿FLQVWUXFWLRQVLQFOXGLQJGUXJQDPHVLQWKH “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. 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\RXUSUHVFULSWLRQEHQH¿WSODQIRUSD\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