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Get Wellcare NA020528 2012-2024

Mail Service Pharmacy Prescription Form Phone 866-740-2539 Please fax completed form to Exactus Pharmacy Solutions Mail Service 877-709-1694. Member Information Member ID Date Patient Name Date of Birth Gender r Male r Female Shipping Address City State Zip Phone Number Allergies r No Known r Aspirin r Codeine r r Peanuts r Sulfa r Other Prescription Information Fax the completed form from the provider office. This is not valid for CII prescriptions. Please make sure the quantity is for a 90-day supply unless otherwise noted. Our Promise We will never auto-ship medications and will verify all prescriptions with member before shipping. Rx Drug Name Strength Directions Quantity Number of Refills DAW IMPORTANT NOTICE It is standard pharmacy practice to substitute generic equivalents for brand name medications. Member Information Member ID Date Patient Name Date of Birth Gender r Male r Female Shipping Address City State Zip Phone Number Allergies r No Known r Aspirin r Codeine r r Peanuts r Sulfa r Other Prescription Information Fax the completed form from the provider office. This is not valid for CII prescriptions. Please make sure the quantity is for a 90-day supply unless otherwise noted* Our Promise We will never auto-ship medications and will verify all prescriptions with member before shipping. Rx Drug Name Strength Directions Quantity Number of Refills DAW IMPORTANT NOTICE It is standard pharmacy practice to substitute generic equivalents for brand name medications. Exactus Pharmacy Solutions Mail Service will dispense an FDA-approved generic equivalent whenever available when permitted by the prescriber and allowed by law. If you do not want a generic equivalent or have questions regarding your mail order prescription please call customer service at 866-740-2539. Prescriber Information MD/ARNP Name DEA NPI Address Fax IMPORTANT WARNING This message is intended for the use of the person or entity to whom it is addressed and may contain information that is privileged and confidential the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering it to the intended recipient you are hereby notified that any dissemination distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message in error please notify us immediately. NA020528PROFRMENG 49158 MD/ARNP Signature WellCare 2012 NA1012. Member Information Member ID Date Patient Name Date of Birth Gender r Male r Female Shipping Address City State Zip Phone Number Allergies r No Known r Aspirin r Codeine r r Peanuts r Sulfa r Other Prescription Information Fax the completed form from the provider office. This is not valid for CII prescriptions. Please make sure the quantity is for a 90-day supply unless otherwise noted* Our Promise We will never auto-ship medications and will verify all prescriptions with member before shipping.

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