If you would like to refill your existing PrecisionRx Specialty Solutions prescription online, please complete the form below. This form should only be used by members who meet the following criteria:

• You have a current prescription for a specialty medication with refills available.
• You will be using the same credit card that you used for your previous order.
• You have had no changes to your insurance since your previous order.
• You do not have an outstanding account balance.

Please note that requested delivery dates cannot be guaranteed.
If you have any questions, if you do not have your prescription number available, or if the criteria above are not met, please contact us at (800) 870-6419.

Required Field *

Insurance Information
Has your insurance changed since your last refill/order? *	Yes No
Patient Information
First Name: *
Last Name: *
Email Address: *
Home Address: *
Home Address 2:
City: *
State: *	(Select) ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Zip Code: *
Home Phone: *	( ) - -
Work Phone:	( ) - -
Cell Phone:	( ) - -
Fax Number:	( ) - -
Shipping Information
Please note :We cannot ship to P.O. Box addresses
Ship To: *	(Select) Home Work Phys Infusion Center Other
Address: * Provide only if any option other than Ship To "Home " option is selected.
Address 2: Provide only if any option other than Ship To "Home " option is selected.
City: * Provide only if any option other than Ship To "Home " option is selected.
State: * Provide only if any option other than Ship To "Home " option is selected.	(Select) ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Zip Code: * Provide only if any option other than Ship To "Home " option is selected.
Refill Request *
Please make sure that you have refills available and your prescription has not expired. Please include the numeric portion of the Prescription Number only.
Prescription Number 1:
Prescription Number 2:
Prescription Number 3:
Prescription Number 4:
Prescription Number 5:
Prescription Number 6:
Prescription Number 7:
Payment Information
If your credit card information has changed, please contact us at 800-870-6419 so we can update our records.
Pre-approved charge limit: Please enter the maximum amount that we can charge your credit card for your prescription co-payment. If your co-payment amount exceeds the maximum amount specified, you will be contacted via phone for authorization
Payment Type: *	(Select) American Express Discover MasterCard Visa
Last Four Digits of Credit Card Number: *
Name As It Appears On Card: *
Credit Card Expiration Date: *	Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Credit Card Billing Address
Same As Home
Address: * Required only if Same As Home option is NOT checked.
Address 2:
City: * Required only if Same As Home option is NOT checked.
State: * Required only if Same As Home option is NOT checked.	(Select) ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Zip Code: * Required only if Same As Home option is NOT checked.
Delivery Date Information
Please select a medication delivery date from the calendar. Please note that the earliest possible date for selection is 3 business days from current date. Saturday, Sunday, and some holidays are not eligible days for medication delivery.
Select a Delivery Date: * Enter date in the following format - mm/dd/yyyy.
Other Information
Do you require a Sharps Container? *	Yes No
Do you need Supplies? *	Yes No
Supply Request * Required only if you need supplies.
Shipping signature required? * If your prescription is sent to an address other than your home, a signature may be required.	Yes No
Would you like to receive a call from a nurse or pharmacist? *	Yes No