Member Self-Enrollment

Patient Information

State *
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Date of Birth *

(This is the employer of the covered family member who holds the insurance.)

Prescription Information

(This value cannot be changed. If this is the wrong medication refresh the page and start again.)

Is this a new prescription for you? *
—Please choose an option—YesNo

Allergies (optional)

Scan or Photo of Drivers License (optional)
(file size limit: 5mb)

Scan or Photo of Prescription (optional)
(file size limit: 5mb)

Scan or Photo of Medical Insurance Card (optional)
(file size limit: 5mb)

Other Medication(s) (optional)