Enjoy the convenience of having your prescriptions delivered to your home free of charge! No co-pays OR shipping charges!

Convenient Home Delivery:
Instead of making a trip to your local pharmacy each month, receive up to a three month supply of your prescriptions directly to your home.

Sign Up Now!

• Required
Patient Name •	Date of Birth (mm/dd/yyyy) •

Physical Address •

Physical Address (Line 2)

City •	State •	Zip Code •
	-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NF NS ON PE QC SK

Email Address •	Daytime Phone •	Alternate Phone

From Prescription Card:

Member ID •	Group Number •

Allergy Info:

No Allergies Codeine Sulfa Aspirin Penicillin Other If other allergies

Health Conditions:

High Blood Pressure Thyroid Diabetes Glaucoma Heart Conditions Other If other condition(s)

Current Medications (including over the counter medicine)

Doctor/Provider Information:

Physician Name

Address

Address (Line 2)

Phone	Fax

 

 

• Submit a Referral
• Request a Quote
• Access Sequoia
• Research a Drug
• Locate a Pharmacy
• Access Our Formulary
• Ask the Pharmacist
• Send Us Feedback