Resources

Additional information is available on the Contact Us page.


Co-pay Assistance Request Form

Use the Co-pay Assistance Request Form if your prescription was filled at your pharmacy.

Medical Benefit Co-pay Assistance Request Form

Use the Medical Benefit Co-pay Assistance Request Form if your prescription was filled at your prescriber's office.

KIS Co-pay Assistance Request Form

Use this Co-pay assistance form if your card references KIS

SCE Co-pay Assistance Request Form

Use this Co-pay assistance form if your card references SCE

Medical Co-pay Authorization Form

This form is required if you will be submitting medical co-pay assistance requests.