IMPORTANT CHANGES TO YOUR PHARMACY BENEFITS
Effective January 1, 2017
Any questions concerning SCT new pharmacy benefit changes,
please contact US Script/Envolve Customer Service Center at (800) 460-8988,
24 hours a day, seven days a week.
In order to utilize this electronic Application for Benefits available to the Scott
Class Members, SCTMS will require either your Federal Social Security Number OR Louisiana Driver's License Number. This information
will only be used to verify your identity prior to submission of your Application
to the Court for final determination of your Class.
By seeking to be approved to participate in the smoking cessation program as a Scott
class beneficiary who meets the eligibility requirements of such program, you hereby
expressly acknowledge, agree and irrevocably consent that the Smoking Cessation
Trust, and its authorized agents and representatives, may verify the information
provided to us by you, including but not limited to your Louisiana residency status,
social security number, driver's license, medical history, and smoking history.
If you are unable to provide either your SSN# or DL# please call SCT-Management
Services at (504) 529-5665 to speak to an enrollment specialist about an alternative
method to register.
Your Primary Insurance information is not required, however, it can assist SCTMS
in correctly processing your Smoking Cessation claims.
I certify that the information above is true and accurate
to the best of my knowledge. I hereby authorize my health care provider to release
my information identified in this form to SCT Management Services. I authorize the
release of my Protected Health Information (PHI) for the purpose of contacting me,
coaching me in quitting smoking, giving feedback regarding my quit progress to my
healthcare provider(s), and permission for my healthcare provider to forward my
information to other health care providers (ex., the quit-line for telephone counseling)
directly or indirectly involved in treating me relating specifically to smoking
Under penalty of perjury, I affirmatively state that:
Please enter a Password to enable you to access your profile when your application is approved.