Form Instructions
HMSA’s Mail Order Prescription Drug Program
Precision Rx is a mail order prescription drug program.
Having your daily maintenance medications delivered to your home is safe and convenient.
Here’s how to get started:
To avoid delays, please make sure your information is complete.
- Please print and fill out this form.
- If your health plan includes prescription drug benefits, call HMSA at the number
on the back of your HMSA card to ask for the maximum amount that can be ordered
at one time by mail order (for instance, 90-day supply) and the copayment for that
amount under Precision Rx. The representative will need to know the drug coverage
code (the number following the word “drug”) on your HMSA card.
Note: Not all drug plans have a mail-order benefit.
- Ask your physician for a prescription for that amount, plus refills.
- Complete the Order Form and Patient Profile (Part 1).
- You must include your subscriber number and group number listed on your HMSA card.
Note: You can order maintenance medications for more than one family member as long
as they are covered under your HMSA plan. Use the same form if all prescriptions
fit.
- Complete and sign the medical information section (Part 2). Be sure to list all drug allergies.
- Print your name, subscriber number, and date of birth on the back of each prescription.
- Complete the payment information section at the bottom of Part 2. (Check, money order or credit card. No cash, please.)
- Mail the original prescription(s), copayment, and patient profile(s) to:
Precision Rx
P.O. Box 961025
Fort Worth, TX 76161-9863