Follow the steps to complete your online application.

1. Press the ‘Get Form’ button to obtain the application form and open it in your preferred editing tool.
2. Begin by filling out the Applicant Information section (Section A). Include your last name, first name, middle initial, social security number, date of birth, address, and contact information.
3. If applicable, move to Section B to provide the Spouse Information. Complete the same fields required for the applicant, including both social security numbers and dates of birth.
4. Complete the Health Survey section. This survey, while optional, provides important insights into health status and should reflect personal health conditions.
5. Proceed to fill out the Other Coverage sections. Here, you will detail any additional prescription or health insurance coverage for both the applicant and spouse.
6. Review the Certification and Authorization Statements section. Ensure that you understand each provision before signing to authorize the release of information.
7. Check that all required fields are filled out correctly, including any signatures in Section D.
8. Once all information is accurately entered, save your changes, and download or print the completed form.
9. Finally, submit your application via fax, mail, or online as specified in the submission instructions. Keep a copy for your records.

Complete your application online today to access essential prescription benefits.