RX LOOKUP REQUEST Prescription Lookup Request Step 1 of 5 - General Information 20% Name(Required) First Last Phone(Required)Email Resident Zip(Required) Prescription List(Required)Please enter your prescription list, excluding any over the counter supplements, etc. 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/CVSKroger/Fred Meyer/SmithsRite-AidSafewayHaggensWalgreensBartell DrugsWal-Mart/Sam's ClubSav-On/AlbertsonsMail OrderPharmacy Not ListedName of Preferred Pharmacy(Required) Additional Prescriptions/Questions/Comments/NotesPlease provide us with any other information that may help, otherwise click the NEXT button below. 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 agreeCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ