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All fields except for the Prescription Number and Coverage Date are required. For more information about a particular field, click the
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info button in the far right of the field.
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A value is required.
Exceeded maximum number of characters.
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A value is required.
Exceeded maximum number of characters.
Numbers/letters only (found on Plan ID Card)
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Exceeded maximum number of characters.
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Example: 04/05/1982
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Should be Ex:mm/dd/yyyy.
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Please enter valid email
Example: (123) 456-7890
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Please enter valid US phone number.
Numbers/letters only
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Minimum number of characters not met.
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Example: blue*light24
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Minimum number of characters not met.
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Retype password
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Optional Fields
Prescription Number
Numbers only (OPTIONAL)
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Exceeded maximum number of characters.
Coverage Date
Example: 05/23/2022 (OPTIONAL)
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A value is required.
Should be Ex:mm/dd/yyyy.

Access to this site is restricted to members to make the best use of their benefits. All other access is prohibited.

By creating this account, you agree to the following:

  1. That the name, date of birth and subscriber number are yours or belong to an individual for whom you have legal access to his or her pharmacy benefit information.
  2. You understand that access to this site is monitored and logged and that unauthorized access will be prosecuted to the full extent of the law.
  3. The email address and phone number you provide are yours, are valid and can be used to contact you to resolve issues with this account. For example, if you need to reset your password, we will email the new password to the email address you provide. This information will not be provided to third parties for marketing purposes.