Haverhillmeds enrollment package with formulary 09.13

HaverhillMeds is an optional international mail order program designed for the Employees,
Retirees and Dependents of the City of Haverhill, MA. Your list of qualified medications is on
Copayments:
All copayments have been waived for this program only.
HaverhillMeds Vs. Current local purchase plan
Annual Cost
No Copays!
$200 / Script
Vs. $110 x 4 = $440 / Script
To place your first order simply complete the enrollment form and include a new prescription for each medication. Please allow 4 weeks for delivery. Ask your doctor for a prescription for a 3 month supply with 3 refills. We will call you prior
to each renewal to ensure that you have a continuous supply. Medications must be taken for 30 days before ordering through HaverhillMeds.

RETURN YOUR COMPLETED AND SIGNED ENROLLMENT FORM AND ORIGINAL PRESCRIPTIONS:
By Faxing to: 1-866-715-(MEDS) 6337 toll free
Faxed prescriptions must be sent directly from the doctor's office.
OR
By Mailing to: HaverhillMeds
P.O. Box 44650
Detroit, Michigan 48244-0650
More forms are available:
Additional forms may be obtained at the Personnel Office, by printing them from the website
at www.HaverhillMeds.com or by contacting our Customer Service Representatives toll
free at 1-866-893-(MEDS) 6337.
Welcome to

For More Information: Call 1-866-893-MEDS (6337)
LAMICTAL DISPERSIBLE 25MG RHINOCORT AQ 64MCG SANCTURA XR 60MG DIOVAN HCT (G) 80/12.5MG
SEREVENT DISKUS 50MCG DIOVAN HCT (G) 160/12.5MG
LEXAPRO (G) 10MG
SEROQUEL (G) 25MG
ABILIFY DISCMELT 10MG DIOVAN HCT (G) 160/25MG
LEXAPRO (G) 20MG
SEROQUEL (G) 100MG
ABILIFY DISCMELT 15MG DIOVAN HCT (G) 320/12.5MG
SEROQUEL XR 50MG ABILIFY SOLUTION 1MG/ML DIOVAN HCT (G) 320/25MG
LIPITOR (G) 10MG
SEROQUEL XR 150MG DOVONEX CREAM 50MCG LIPITOR (G) 20MG
SEROQUEL XR 200MG DULERA 100MCG/5MCG LIPITOR (G) 40MG
SEROQUEL XR 300MG DULERA 200MCG/5MCG LIPITOR (G) 80MG
SEROQUEL XR 400MG LOCOID LIPOCREAM 0.1% ACTOS (G) 30MG
EFFEXOR XR (G) 37.5MG
LOCOID OINTMENT 0.1% ACTOS (G) 45MG
EFFEXOR XR (G) 75MG
EFFEXOR XR (G) 150MG
LUMIGAN OPHTH 0.01% STALEVO (G) 50MG
ADVAIR DISKUS 100MCG MESTINON TS 180MG STALEVO (G) 100MG
ADVAIR DISKUS 250MCG STALEVO (G) 125MG
ADVAIR DISKUS 500MCG ADVAIR HFA 45/21MCG ADVAIR HFA 115/21MCG MICARDIS HCT 40/12.5MG ADVAIR HFA 230/21MCG MICARDIS HCT 80/25MG AGGRENOX 200/25MG MIGRANAL NASAL SPRAY 4MG/ML TAZORAC CREAM 0.05% MIRAPEX ER 0.375MG TAZORAC CREAM 0.1% ALOCRIL OPHTH 2% EPIPEN JR 0.15MG MIRAPEX ER 0.75MG TAZORAC GEL 0.05% ALPHAGAN-P OPHTH SOLUTION (G)
MIRAPEX ER 1.5MG TAZORAC GEL 0.1% EPIVIR/HBV 100MG MIRAPEX ER 2.25MG TOBREX OINTMENT 0.3% ALVESCO 80MCG 100MCG ESTROGEL GEL 0.06% MIRAPEX ER 3.75MG ALVESCO 160MG 200MCG MIRAPEX ER 4.5MG AMERGE (G) 1MG
EXELON 4.6 MG/24HR EXELON 9.5MG/24HR TRAVATAN Z OPHTH SOLUTION ASMANEX TWISTHALER 220MCG ATRIPLA 600-200-300MG EXFORGE 10/160MG TRIBENZOR 20/5/12.5MG ATROVENT HFA 20UG TRIBENZOR 40/5/12.5MG AVALIDE (G) 150MG/12.5MG
EXFORGE 320/10MG TRIBENZOR 40/5/25MG AVALIDE (G) 300MG/12.5MG
EXFORGE HCT 160/12.5/5 TRIBENZOR 40/10/12.5MG EXFORGE HCT 160/12.5/10 TRIBENZOR 40/10/25MG AVAPRO (G) 75MG
EXFORGE HCT 160/25/5 TRUVADA 200-300MG AVAPRO (G) 150MG
EXFORGE HCT 160/25/10 AVAPRO (G) 300MG
EXFORGE HCT 320/25/10 NORITATE CREAM 1% AZOPT OPHTH DROPS 1% ORTHO-TRI-CYCLEN LO VERAMYST 27.5MCG BACTROBAN CREAM 2% FLOMAX (G) 0.4MG
PATANOL OPHTH SOLUTION 0.1% FLOVENT 44MCG 50MCG FLOVENT 110MCG 125MCG PLAVIX (G) 75MG
VIRAMUNE XR 400MG FLOVENT 220MCG 250MCG VIVELLE-DOT 25MCG BECONASE AQ 0.04% FLOVENT DISKUS 50MCG VIVELLE-DOT 37.5MCG FLOVENT DISKUS 100MCG VIVELLE-DOT 50MCG FLOVENT DISKUS 250MCG VIVELLE-DOT 75MCG BENICAR HCT 20MG/12.5MG FORADIL + AEROLIZER 12MCG VIVELLE-DOT 100MCG BENICAR HCT 40MG/12.5MG FOSAMAX-D 70/2800MG WELLBUTRIN XL (G) 150MG
BENICAR HCT 40MG/25MG FOSRENOL CHEW 250MG PREMARIN 0.625MG WELLBUTRIN XL (G) 300MG
FOSRENOL CHEW 500MG FOSRENOL CHEW 1000MG PREMPRO 0.3/1.5MG BETOPTIC S OPHTH 0.25% PREMPRO 0.625MG/2.5MG BONIVA (G) 150MG
PREMPRO 0.625MG/5MG PREVACID SOLUTAB 15MG PREVACID SOLUTAB 30MG CLIMARA PRO 0.045/0.015 GLUCAGEN HYPOKIT 1MG ZOMIG ZMT 2.5MG (1X6) ZOVIRAX CREAM 5% CORGARD (G) 80MG
IMITREX AUTOINJECTOR STATDOSE (G)
PROSCAR (G) 5MG
6MG/0.5ML
PROTONIX (G) 20MG
IMITREX NASAL SPRAY (G) 5MG-2DOSE
PROTONIX (G) 40MG
IMITREX NASAL SPRAY (G) 20MG-2DOSE
PROTOPIC OINTMENT 0.03% PROTOPIC OINTMENT 0.1% QVAR 40MCG 50MCG QVAR 80MCG 100MCG CUTIVATE CREAM 0.05% JALYN 0.5MG/0.4MG CUTIVATE OINTMENT 0.005% JENTADUETO 2.5MG/850MG RETIN A MICRO GEL 0.04% JENTADUETO 2.5MG/1000MG RETIN A MICRO GEL 0.1% PUMP DEXILANT DR 30MG KEPPRA (G) 750MG
DEXILANT DR 60MG LAMICTAL (G) 25MG
RHEUMATREX 2.5MG DIFFERIN GEL 0.3% LAMICTAL (G) 150MG
RHINOCORT AQ 32MCG NOTE: Medication names appearing with (G) are available in a Generic version from your local or U.S. mail order pharmacy. For a greater
savings to your healthcare plan, ask your physician about taking a Generic equivalent of your medication.

This list is subject to change. Please call 1-866-893-6337 toll free to verify the availability of your medication through this program. September 2013 Employee Enrollment Form
MEMBER #:
FAX DIRECTLY FROM YOUR DOCTOR'S OFFICE WITH YOUR PRESCRIPTION(S) TOLL FREE TO: 1-866-715-(MEDS)6337
MAIL TO: HaverhillMeds, P.O. BOX 44650, DETROIT, MI., U.S.A. 48244-0650 PHONE TOLL FREE: 1-866-893-(MEDS)6337
PATIENT INFORMATION: (please print)
Birth date
DD/MM/YYYY
Please request a 3-month
supply of medication with Phone (Home)
Phone (Work or Cell)
3 refills.
First Name
Last Name
New-to-you medications must
be domestically prescribed,
Street Address
filled and taken for a period of no less than 30 days. City/State
List all prescription, non-prescription, over-the-counter
Strength
Reason for Taking
Daily Use
medications, herbal, nutritional and vitamin supplements.
Example: Lipitor (This is not a prescription.) Ex: 10 mg Ex: Cholesterol Ex: 1 / day MEDICAL HISTORY: (If needed, please attach a separate sheet of paper) Male Female
(i) Operations: e.g. Hysterectomy, Gall Bladder, Heart Operations, etc.

(ii) Hospitalizations: (stays in hospital past 5 years)

(iii) Present Illness: (ongoing) e.g. Diabetes, Heart Disease, Osteoporosis, etc.
(iv) Drug Allergies:  NO YES If yes, please specify:

AUTHORIZATION: I confirm that a Physician will regularly monitor me and that I have had a physical examination within the past
12 months. I verify that I have taken the medications ordered through this program for a period of more than 30 days. I certify that I
have read, understand and agree to the terms of agreement on the reverse and that the information provided by me is accurate and
true. I request and authorize the City of Haverhill, MA, to pay for all services, fees and amounts relating to the prescription
medications that I will obtain through this service.
Patient Signature:
Date: (DD/MM/YY)
CONFIRMATION AND REPRESENTATIONS
I, the undersigned, am entering into this agreement with CanaRx Group Inc. ("CanaRx") in order that I may obtain access to
medically necessary prescription drugs at low costs.
I am of the age of majority in the jurisdiction in which I ordinarily reside; I am not restricted from making my own medical decisions under the laws of the jurisdiction in which I ordinarily reside; The medications that I have requested that CanaRx facilitate my obtaining were prescribed by a duly qualified and licensed medical practitioner in the United States; 4. I have not violated any laws in the jurisdiction in which I ordinarily reside, in obtaining the prescription for the ordered product; 5. This prescription has not been altered in any way nor has it been filled previously. I agree to mail or fax from my doctor's office the original copy of the prescription to CanaRx; I am under the ongoing care of a physician in my residing jurisdiction (my "U.S. physician"), and therefore, I am not seeking or relying on any medical information from CanaRx or any CanaRx contracted physician; My prescription will not be used in any way whatsoever except as prescribed by my medical practitioner who originally issued the prescription; I will not permit anyone else to use the prescription or any medications which I receive; I will use any medications obtained for me by CanaRx strictly in accordance with the instructions provided by the physician who prescribed the medications; and 10. In the event that I suffer any side effects from any medications I receive through the services of CanaRx, I will immediately contact my U.S. physician. 11. I certify that I am a resident of the United States and not a resident of any other country. AUTHORIZATION AND CONSENT
I further provide my authorization and consent to the following:
I hereby appoint CanaRx and its delegates or contractors as my paid agent and attorney for the purposes of obtaining prescriptions which correspond to the prescriptions provided by my U.S. physician. I authorize CanaRx and its delegates or contractors to arrange the purchase and delivery of the medications prescribed to me on the terms outlined in this agreement and to the same extent as if I personally took such steps. 3. I consent and authorize CanaRx to collect my personal medical information and to maintain on file the information necessary to verify and process future orders, including but not limited to my full name, address, phone number, complete medical history and payment information. I authorize my U.S. physician and CanaRx to release any and all information required in connection with my physical condition, including but not limited to all X-rays, medical records, medical reports, progress notes, nurses' notes, reports on diagnostic tests, medical opinions and/or any other knowledge or information which they may possess to a CanaRx contracted physician who may be required to review my health record for the purposes of being in a position to evaluate the medical necessity and indications for prescription medication. I authorize the CanaRx contracted physician to contact my U.S. physician to discuss my prescription if necessary. I further authorize the CanaRx contracted physician to issue prescriptions for medications I have ordered only if he/she deems it advisable and appropriate. 7. I further authorize the CanaRx contracted physician to release any and all information that may be required by any CanaRx contracted pharmacy for the purpose of having my prescriptions filled. 8. I further authorize CanaRx to make payments on my behalf to the CanaRx contracted pharmacy for the filling of my prescriptions and to the CanaRx contracted physician for services rendered on my behalf. ACKNOWLEDGEMENT AND RELEASE
I hereby make the following acknowledgments and releases to CanaRx, including all of its employees, its contractors, including
physicians, pharmacists, pharmacy technicians, nurses, receptionists and staff:
I acknowledge that my U.S. physician is my primary physician and the CanaRx contacted physician is being asked only to review the information contained in the Personal Medical History for the purpose of authorizing any properly prescribed medications for fulfillment from a CanaRx contracted pharmacy. 2. I acknowledge that CanaRx has made no representations or warranties to me, including, without limitation, representations or warranties regarding the use of fitness for any particular purpose of the medications delivered (including, without limitation, its appropriateness for curing or helping relieve any particular ailment, illness or disease, or its potential or actual side or adverse effects whether previously known or unknown). 3. I acknowledge that I wish to obtain a prescription from a CanaRx contracted physician and have enlisted the services of CanaRx to facilitate this matter. I understand and appreciate that the CanaRx contracted physician will rely on the accuracy of the examination and prescription provided by my U.S. physician. I hereby specifically acknowledge that I am aware that CanaRx may transmit my personal information by electronic means (for example fax, or secure internet) to its agents, contracted physicians and pharmacies. I understand that the use of electronic means will enhance the efficiency and timeliness of processing my order. I also understand that CanaRx, as a custodian of my personal information, will take all appropriate precautions to protect my personal information from improper disclosure or use. I hereby consent to CanaRx's transmission of my personal information by electronic means to its agents, contracted physicians and pharmacies. 5. I release CanaRx and all of their officers and directors, agents, employees and contractors from any and all causes of action with respect to errors or omissions by the company or agency responsible for transporting my order. I acknowledge that I have purchased my medications internationally for personal use and understand that my medications may be subject to U.S. border seizure. I specifically confirm, acknowledge and agree that title to my medication passes to me when my medications are shipped from the CanaRx contracted pharmacy. I acknowledge that CanaRx, as my paid agent, requires payment in full prior to shipment and that my order may not be returned for a refund or an
exchange.
FURTHER ACKNOWLEDGEMENT & RELEASE
I hereby make the following further acknowledgement and release the plan holder, its employees, officers, agents, heirs and
assigns:
I acknowledge that the plan holder, has made no representations or warranties to me, including without limitation, representations or warranties regard-ing the use for any particular purpose the medication (s) delivered, including without limitation, its appropriateness for curing or helping relieve any particular ailment, illness or disease or its potential or actual side or adverse effects whether previously known or unknown. I acknowledge that child protective packaging may not be used in filling my prescription. I promise that upon my receipt of the medicine I will take all steps necessary to prevent any child from having unauthorized access to the medicine. I herby release CanaRx Group and all its officer, directors, agents, employees, and contractors, including the pharmacy that fills my prescription, from any and all claims arising from or relating to the use of, or failure to use, child protective packaging in filling my prescription . I release the plan holder its officers, employees, agents, heirs and assigns from (i) any and all causes of actions with respect to errors or omissions by the company or agency responsible for transporting my order; (ii) any and all causes of actions with respect to errors or omissions by CanaRx Group Inc. in obtaining the prescription medications to fill my order; (iii) any and all causes of actions regarding the use of any medications delivered through this program which are utilized for any purpose whatsoever. Dependent Enrollment Form
MEMBER #:
FAX DIRECTLY FROM YOUR DOCTOR'S OFFICE WITH YOUR PRESCRIPTION(S) TOLL FREE TO: 1-866-715-(MEDS)6337
MAIL TO: HaverhillMeds, P.O. BOX 44650, DETROIT, MI., U.S.A. 48244-0650 PHONE TOLL FREE: 1-866-893-(MEDS)6337
PATIENT INFORMATION: (please print) Birth date
 Spouse
DD/MM/YYYY
 Dependent
Please request a 3-month
supply of medication with Phone (Home)
Phone (Work or Cell)
3 refills.
First Name
Last Name
New-to-you medications must
be domestically prescribed, filled and taken for a period of Street Address

no less than 30 days. City/State
List all prescription, non-prescription, over-the-counter
Strength
Reason for Taking
Daily Use
medications, herbal, nutritional and vitamin supplements.
Example: Lipitor (This is not a prescription.) Ex: 10 mg Ex: Cholesterol Ex: 1 / day MEDICAL HISTORY: (If needed, please attach a separate sheet of paper)
Male Female
(i) Operations: e.g. Hysterectomy, Gall Bladder, Heart Operations, etc.

(ii) Hospitalizations: (stays in hospital past 5 years)

(iii) Present Illness: (ongoing) e.g. Diabetes, Heart Disease, Osteoporosis, etc.
(iv) Drug Allergies:  NO YES If yes, please specify:

AUTHORIZATION IF THE PATIENT IS A DEPENDENT CHILD UNDER AGE 18
I certify this to be a true and accurate statement of my Dependent's medical history. I confirm that he/she has been, and will be, regularly
monitored by a U.S. Physician and has had a physical examination within the past 12 months. I verify that he/she has taken the above listed
medications for a period of more than 30 days. I certify that I have read, understand and agree to the Terms of Agreement on the reverse and that
the information provided above is accurate and true. I request and authorize the City of Haverhill, MA, to pay for any and all services, fees and
amounts relating to the prescription medications that I will obtain through this service.

Parent's/Guardian's Signature:
Date: (DD/MM/YY)

AUTHORIZATION IF THE PATIENT IS THE SPOUSE OR A DEPENDENT CHILD AGE 18 AND OVER
I confirm that a U.S. Physician will regularly monitor me and that I have had a physical examination within the past 12 months. I verify that I have
taken the above listed medication for a period of more than 30 days. I certify that I have read, understand and agree to the Terms of Agreement on
the reverse and that the information provided by me is accurate and true. I request and authorize the City of Haverhill, MA, to pay for any and all
services, fees and amounts relating to the prescription medications that I will obtain through this service.
Patient Signature:
Date: (DD/MM/YY)
CONFIRMATION AND REPRESENTATIONS
I, the undersigned, am entering into this agreement with CanaRx Group Inc. ("CanaRx") in order that I may obtain access to
medically necessary prescription drugs at low costs.
I am of the age of majority in the jurisdiction in which I ordinarily reside; I am not restricted from making my own medical decisions under the laws of the jurisdiction in which I ordinarily reside; The medications that I have requested that CanaRx facilitate my obtaining were prescribed by a duly qualified and licensed medical practitioner in the United States; 4. I have not violated any laws in the jurisdiction in which I ordinarily reside, in obtaining the prescription for the ordered product; 5. This prescription has not been altered in any way nor has it been filled previously. I agree to mail or fax from my doctor's office the original copy of the prescription to CanaRx; I am under the ongoing care of a physician in my residing jurisdiction (my "U.S. physician"), and therefore, I am not seeking or relying on any medical information from CanaRx or any CanaRx contracted physician; My prescription will not be used in any way whatsoever except as prescribed by my medical practitioner who originally issued the prescription; I will not permit anyone else to use the prescription or any medications which I receive; I will use any medications obtained for me by CanaRx strictly in accordance with the instructions provided by the physician who prescribed the medications; and 10. In the event that I suffer any side effects from any medications I receive through the services of CanaRx, I will immediately contact my U.S. physician. 11. I certify that I am a resident of the United States and not a resident of any other country. AUTHORIZATION AND CONSENT
I further provide my authorization and consent to the following:
I hereby appoint CanaRx and its delegates or contractors as my paid agent and attorney for the purposes of obtaining prescriptions which correspond to the prescriptions provided by my U.S. physician. I authorize CanaRx and its delegates or contractors to arrange the purchase and delivery of the medications prescribed to me on the terms outlined in this agreement and to the same extent as if I personally took such steps. 3. I consent and authorize CanaRx to collect my personal medical information and to maintain on file the information necessary to verify and process future orders, including but not limited to my full name, address, phone number, complete medical history and payment information. I authorize my U.S. physician and CanaRx to release any and all information required in connection with my physical condition, including but not limited to all X-rays, medical records, medical reports, progress notes, nurses' notes, reports on diagnostic tests, medical opinions and/or any other knowledge or information which they may possess to a CanaRx contracted physician who may be required to review my health record for the purposes of being in a position to evaluate the medical necessity and indications for prescription medication. I authorize the CanaRx contracted physician to contact my U.S. physician to discuss my prescription if necessary. I further authorize the CanaRx contracted physician to issue prescriptions for medications I have ordered only if he/she deems it advisable and appropriate. 7. I further authorize the CanaRx contracted physician to release any and all information that may be required by any CanaRx contracted pharmacy for the purpose of having my prescriptions filled. 8. I further authorize CanaRx to make payments on my behalf to the CanaRx contracted pharmacy for the filling of my prescriptions and to the CanaRx contracted physician for services rendered on my behalf. ACKNOWLEDGEMENT AND RELEASE
I hereby make the following acknowledgments and releases to CanaRx, including all of its employees, its contractors, including
physicians, pharmacists, pharmacy technicians, nurses, receptionists and staff:
I acknowledge that my U.S. physician is my primary physician and the CanaRx contacted physician is being asked only to review the information contained in the Personal Medical History for the purpose of authorizing any properly prescribed medications for fulfillment from a CanaRx contracted pharmacy. 2. I acknowledge that CanaRx has made no representations or warranties to me, including, without limitation, representations or warranties regarding the use of fitness for any particular purpose of the medications delivered (including, without limitation, its appropriateness for curing or helping relieve any particular ailment, illness or disease, or its potential or actual side or adverse effects whether previously known or unknown). 3. I acknowledge that I wish to obtain a prescription from a CanaRx contracted physician and have enlisted the services of CanaRx to facilitate this matter. I understand and appreciate that the CanaRx contracted physician will rely on the accuracy of the examination and prescription provided by my U.S. physician. I hereby specifically acknowledge that I am aware that CanaRx may transmit my personal information by electronic means (for example fax, or secure internet) to its agents, contracted physicians and pharmacies. I understand that the use of electronic means will enhance the efficiency and timeliness of processing my order. I also understand that CanaRx, as a custodian of my personal information, will take all appropriate precautions to protect my personal information from improper disclosure or use. I hereby consent to CanaRx's transmission of my personal information by electronic means to its agents, contracted physicians and pharmacies. 5. I release CanaRx and all of their officers and directors, agents, employees and contractors from any and all causes of action with respect to errors or omissions by the company or agency responsible for transporting my order. I acknowledge that I have purchased my medications internationally for personal use and understand that my medications may be subject to U.S. border seizure. I specifically confirm, acknowledge and agree that title to my medication passes to me when my medications are shipped from the CanaRx contracted pharmacy. I acknowledge that CanaRx, as my paid agent, requires payment in full prior to shipment and that my order may not be returned for a refund or an
exchange.
FURTHER ACKNOWLEDGEMENT & RELEASE
I hereby make the following further acknowledgement and release the plan holder, its employees, officers, agents, heirs and
assigns:
I acknowledge that the plan holder, has made no representations or warranties to me, including without limitation, representations or warranties regard-ing the use for any particular purpose the medication (s) delivered, including without limitation, its appropriateness for curing or helping relieve any particular ailment, illness or disease or its potential or actual side or adverse effects whether previously known or unknown. I acknowledge that child protective packaging may not be used in filling my prescription. I promise that upon my receipt of the medicine I will take all steps necessary to prevent any child from having unauthorized access to the medicine. I herby release CanaRx Group and all its officer, directors, agents, employees, and contractors, including the pharmacy that fills my prescription, from any and all claims arising from or relating to the use of, or failure to use, child protective packaging in filling my prescription . I release the plan holder its officers, employees, agents, heirs and assigns from (i) any and all causes of actions with respect to errors or omissions by the company or agency responsible for transporting my order; (ii) any and all causes of actions with respect to errors or omissions by CanaRx Group Inc. in obtaining the prescription medications to fill my order; (iii) any and all causes of actions regarding the use of any medications delivered through this program which are utilized for any purpose whatsoever.

Source: http://www.ci.haverhill.ma.us/departments/human_resources/docs/HaverhillMeds_Enrollment_Package_Sept_2013.pdf