Send us an inventory of your prescriptions to help determine if an adjustment needs to be made to your coverage. Download the PDF form to your computer, open it up and fill out the fields provided. When you're done, save the form and upload it below. For your privacy, the form will be encrypted for security. If you prefer, you can print this form, fill it out by hand, and fax it to us at 630-477-0775.
Your Prescription Inventory