RX LOOKUP REQUEST Prescription Lookup Request Step 1 of 5 - General Information 20% X/TwitterThis field is for validation purposes and should be left unchanged.Name(Required) First Last Phone(Required)Email Resident Zip(Required) Prescription List(Required)* Please exclude any over-the-counter items. * To add more prescriptions, click the + icon at the end (on the right) of the previous prescription entry.Drug Name (ex: Lisinopril)Dosage (ex: 10mg)Frequency (ex: 1x daily) Add Remove Preferred Pharmacy(Required)Select a PharmacyCostcoTarget/CVSKrogerRite-AidBartell DrugsSafewayHaggensWalgreensWalMartSav-On/AlbertsonsMail OrderPharmacy Not ListedName of Preferred Pharmacy(Required) Questions/Comments/NotesPlease provide any other information that may help with shopping coverage, otherwise click the NEXT button below to continue. Consent(Required)By checking this box, you allow us to contact you regarding our services and products. Any information provided will be used for internal use only. I understand that Benefit Solutions Plus, LLC is bound under regulations to keep all personal information private, and will not sell personal information to any third party company. I agreeCAPTCHA Δ
