Benefit Card Request Form

This form is used to provide a copy of pharmacy Member ID Card information by email to the member specified below. The transmission of this email copy is contingent upon verification of identity. This card copy does not certify eligibility, guarantee payment, or fully reflect the plan's limitations. The card will not reflect your medical benefits information. Please contact your benefits department for your medical benefits information.

Personal Information

Contact Information

By submitting this form, I agree to receive my pharmacy Member ID Card Information through the email provided on this sheet and certify that I am the member specified above.