THE BENEFITS ARE CLEAR PraxisRx Pharmacy Home Delivery PraxisRx Pharmacy Home Delivery is an easy-to-use pharmacy delivery service that works with your pharmacy benefi� t . Use our service for medications you take regularly - both for new and refi� l ls. You can trust our registered pharmacists and experienced team to � fi ll your prescriptions accurately, promptly, and conveniently.
THE FUTURE OF PHARMACY
We look forward to serving your
SAVE TIME No trips to the pharmacy No waiting in line Fast, convenient service Order fewer times per year Free delivery to your door or PO Box
Mail Prescriptions to:
5455 W. Waters Suite 214 Tampa, FL. 33634
1.888.903.7453
A P h a r m a c y a t Yo u r D o o r
HOW TO USE PRAXISRX PHARMACY HOME DELIVERY ADDITIONAL
OBTAINING YOUR PRESCRIPTION PraxisRx Pharmacy can contact your physician for you You can obtain a prescription from your physician and send it to PraxisRx Pharmacy by mail Your Physician can send a prescription to PraxisRx Pharmacy by fax or through electronic prescribing to PraxisRx Pharmacy Be sure to ask your physician to write the prescription for a 90-day supply with three re� fi lls and authorize a one-year supply (when appropriate) Auto refi� l ls may be available to members. Please contact customer service for more information
PAYMENT IS DUE AT TIME OF ORDER Credit Card (you can elect to securely save your credit card information for future online or automated voice refills Check (by mail) Money Order
I N F O R M AT I O N
ABOUT GENERICS Generic medications will be used when available and appropriate. The Food and Drug Administration requires a generic medication to be as safe and e� ff. ective as its brand counterpart. Generic medications are considerably less expensive than brand name drugs.
Provide your phone number in case we need to contact you Provide your e-mail address to receive shipment noti� c ations and refi� l l reminders If you need a new prescription, we will contact your physician We will contact you by phone if your order is delayed.
IF YOU NEED MEDICATION RIGHT AWAY Request two prescriptions from your physician, one for an initial 30-day supply that your local pharmacy can fi� l l immediately, and one for a 90-day supply with three refills to fill through PraxisRx. * By law, prescription fax forms and e-prescriptions are
PraxisRx Pharmacy
CUSTOMER SERVICE
Call toll-free 1.888.903.7453
REMEMBER Allow up to 10 days from the time you mail your prescription until you receive the medication in your mailbox. Faster shipping is available, for an additional cost, by contacting customer service. Contact customer service for additional forms, or visit our website at www.praxisrx.com to print as many as you need.
Call us with your
Fill out the enclosed
Register online at
registration information
registration form
www.praxisrx.com
Visit our website www.praxisrx.com to register or manage your prescriptions online.
MEMBER PORTAL Ci�zens Rx offers a Member Portal to guide and educate members regarding their pharmacy benefits. A�er registering with a secure user name and password, par�cipants can navigate the Member Portal to print a temporary ID card, securely view and print individual medica�on history, order mail service refills, determine drug prices and cost share amounts, locate a nearby pharmacy and more. The Member Portal is also compa�ble with mobile devices allowing for maximum accessibility and easy naviga�on. We invite you to visit us at member.ci�zensrx.com and register today.
AT A GLANCE
Member Portal Login Screen
Dashboard
Drug Lookup
Pharmacy Locator
Via the login screen, members can login to our secure site or register by se�ng their personalized user name and password.
Pharmacy plan informa�on (e.g., drug coverage and cost share informa�on).
At a glance, members can view their personal account informa�on and have easy access to specific plan details.
Locate a Ci�zens Rx par�cipa�ng network pharmacy in your geographic area. Simply enter the desired Zip Code and a map with a list is generated that includes the pharmacy name and loca�on.
AT A GLANCE
Claim History
This sec�on allows members to see their pharmacy claim history, as well as summary claim totals for specified periods of �me. Subscribers can view pharmacy claim history for their minor children. Due to HIPAA privacy, each member will need to register separately to review and print their prescrip�on drug history. Subscribers can view pharmacy claim history for their minor children.
Informa�on Center Downloads
Mail Orders (plan specific)
Benefits Info - Plan Info
Benefits Info - ID Card
This sec�on includes useful forms such as Pa�ent Bill of Rights, Direct Member Reimbursement and, if applicable a copy of the Prescrip�on Drug Formulary, Preferred Drug List, and Excluded Medica�ons List.
Members can easily view and u�lize their account summary.
Par�cipants are redirected to the PraxisRx website with the op�on to speak to PraxisRx to get started using the mail order pharmacy program. Exis�ng mail order par�cipants have the op�on to login to proceed with a medica�on refill request.
Create and print a temporary ID card that can be presented to the Network Pharmacy to access your prescrip�on drug benefits. The associate at the pharmacy can u�lize the informa�on on the temporary ID card to process your prescrip�on drug claims.
1144 Lake Street • Oak Park, IL 60301 • (888) 545 1120 • Info@ci�zensrx.com • www.ci�zensrx.com
Please complete and fax or mail to the address below: (888) 958-2831 5455 W Water Ave Suite 214 Tampa, FL 33634
888-903-7453 | WWW.PRAXISRX.COM
MEMBER INFORMATION CARDHOLDER ID#
(REFER TO ID CARD)
GROUP # M F (REFER TO ID CARD IF APPLICABLE)
LAST NAME OF CARDHOLDER
FIRST NAME OF CARDHOLDER
DELIVERY ADDRESS (STREET AND APARTMENT NUMBER) CITY
STATE
ZIP CODE
_
EMAIL ADDRESS
DAYTIME PHONE NUMBER _
Drug Allergies:
No Known Allergy Aspirin Health Condi�ons:
Arthri�s Asthma Depression
DATE OF BIRTH (MM/DD/YYYY) _ _
_
GENDER
Codeine Erythromycin
Iodine Penicillin Sulfa Other ________________________________________________________
Diabetes Epilepsy Glaucoma
Heart Condi�on High Cholesterol Ulcer High Blood Pressure Thyroid Other ________________________________________________________
List any OTC, herbal, or other medica�ons you take regularly: _________________________________________________________
PAYMENT OPTIONS Payment is due with each order. Do not send cash. If you use a credit card for payment, PraxisRx will bill your credit card for your por�on of the drug cost, any special delivery charges and any outstanding balance due.
Credit Card Type (Our preferred payment method for faster service)
MasterCard Visa Discover American Express Use credit card on file Please place credit card on file for future orders ACCOUNT NUMBER
EXPIRATION DATE
/ Check or money order enclosed.
SECURITY CODE
Cardholder Signature: _______________________________________ Date: ______________
NOTES TO PHARMACY
PLEASE READ AND SIGN TO CONFIRM ORDER I cer�fy that the informa�on provided on this form is correct and authorize the release of informa�on regarding medical history, treatment and prescrip�on drug history to PraxisRx Pharmacy. Signature: _________________________________________________________________________ Date: _____________________ To refuse generics check here () AND sign and date. PraxisRx Pharmacy subs�tutes generics when they are medically equivalent to the brand drug prescribed by the doctor. Please sign and date the statement below if you DO NOT want to receive generic products. “I understand that I have the right to refuse generic medica�ons. I understand this may result in a high cost to me, that I am responsible for payment, and that the drugs are not returnable. When my doctor prescribes a brand drug, I wish to receive the brand drug only and accept the condi�ons.” Signature: _________________________________________________________________________ Date: _____________________