Mail Order Pharmacy Refill Request

It's easy to refill your mail order pharmacy prescriptions right here using the form below.

How do I find my prescription number?

Your prescription number is on the left side of the prescription label as shown in the example above. The name of the medication and the number of refills remaining are at the bottom of the label (highlighted in yellow). Please be sure you are requesting the correct medication.

If you need help please call Pharmacy Member Services:

Please be sure the pharmacy has a method of payment on file to avoid delays in your prescription order! 

Co-payments at these locations are as follows:

Retail Network Pharmacies (e.g. Rite Aid, CVS, Walgreens)
(up to a 30 day supply)

Martin’s Point Onsite and Mail Order Pharmacies
(up to a 90 day supply)

  Current * Effective 1/1/20 Current * Effective 1/1/20

Tier 1)





Brand name (Tier 2)





Nonformulary (Tier 3)

Brands and Generics





Non-Covered Drugs (Tier 4)

100% cost of the drug

100% cost of the drug

100% cost of the drug

100% cost of the drug

To complete the refill request form below

Enter your prescription number, date of birth, and primary ZIP code. Please use the comment box for any special requests or questions you may have. If there are no refills on your prescription, please allow extra time for processing for the pharmacy to contact your provider. 

Refill Request

Enter your refill request here. If you have previously entered a request, you can check its status by entering the prescription number in the "Refill Status" section below. Then click the "Check Status" button.
* Hover here for instructions.

Refill Status

To check the status of a refill, please enter your Prescription number below. (You no longer need a confirmation number.)