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Please complete all of the form steps to obtain prescription information. First select the type of prescription processing , then enter the Social Security Number information. Next, specify up to 19 prescriptions which you would like to refill. Then, select the pharmacy where you would like to pick up your medications. Finally, click on the "Send this Request" button to submit your request.

Step 1
Select a prescription option
Prescription Status          Refill Prescription         

Step 2
Please enter the last four digits of your sponsor's social security number
Step 3
Enter the prescription number Prescription #1

If you have more than one prescription to refill, use the additional 18 locations below.
    Rx #2       Rx #3       Rx #4  
    Rx #5       Rx #6       Rx #7  
    Rx #8       Rx #9       Rx #10
    Rx #11     Rx #12     Rx #13
    Rx #14     Rx #15     Rx #16
    Rx #17     Rx #18     Rx #19

if you have more prescriptions to refill, return to this page and enter the remainder of your prescriptions.

Step 4
Pharmacy Location  

Step 5