Forms and Cards

Forms to 

mail in a prescription?  
To mail in a prescription your doctor has already written, you can:
Save time by printing mail order forms online and mailing completed forms and your prescription to:
Medco Health Solutions of Fairfield
P.O. Box 747000
Cincinnati, OH 45274-7000
Prescription mail order form

Health, allergy, and medical questionnaire
Print this form if this is your first mail service order or if you need to report any changes in your health. Return your questionnaire with your prescription or refill order form.

Request mail order forms to be mailed to you. You should expect to receive your order in seven to 10 days.
Forms to 

request a new prescription
Print and bring a fax form to your doctor to request new prescriptions. This form can be completed and faxed to our mail order pharmacy by your doctor.

forms for retail pharmacy purchases
Request claim forms to be mailed to you so you may submit expenses for medications you purchased at a retail pharmacy. You should expect to receive your order in seven to 10 days.
Or, view and print a .pdf version of the claim form. You will need to download a free copy of Adobe® Reader® if you do not have it installed already.

Print your temporary prescription card
You can view and print a temporary prescription card that will display in your browser and can be printed on any printer.

Shopping cart
no items in the cart

Save on prescriptions.

Refill Too Soon Information.
In the event your medication refill will not process at the pharmacy because it was requested prior to the expiration date of your last medication fill ("refill too soon"), you may contact the Customer Service number on your ID card to determine if an exception is available. Exceptions to filling a medication prior to a scheduled refill date can be made in certain circumstances such as, a vacation supply is needed or the daily dose or therapy is changed by the prescriber.