Mail order drugs
We are pleased to offer two convenient ways to order and receive your prescription medications.
You can order your prescriptions for rapid mail delivery from Samaritan Health Services.
Prescription Mail Order (PDF):
Use this form when you have a written prescription that you are mailing to Samaritan Health Services.
Samaritan Pharmacy Services FAX Order Form (PDF):
Provide this form to your physician to fax your prescription to Samaritan Health Services.
Samaritan Pharmacy Services Prescription Transfer Request (PDF):
Use this form to conveniently transfer all your prescriptions to Samaritan Health Services. We will contact the pharmacies you list on the form for you and have the prescriptions transferred.
Envision Rx Options Mail Order Service
Please call Customer Service to sign up for Envision Rx Options mail order service.
Extra help with prescription drug costs
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your State Medicaid office.
In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.
Last modified: October 1, 2012
H3811_MA4001_2012A CMS Approved October 24, 2012