Pharmacy Benefit

Include Street, City, State, Landmark

Medication Details (Drug 1)

name of medication

e.g 2 tablets daily

e.g 500mg

1-month refill, 3-month refill, e.t.c

Medication Details (Drug 2)

name of medication

e.g 2 tablets daily

e.g 500mg

1-month refill, 3-month refill, e.t.c

Medication Details (Drug 3)

name of medication

e.g 2 tablets daily

e.g 500mg

1-month refill, 3-month refill, e.t.c

Medication Details (Drug 4)

name of medication

e.g 2 tablets daily

e.g 500mg

1-month refill, 3-month refill, e.t.c

Medication Details (Drug 5)

name of medication

e.g 2 tablets daily

e.g 500mg

1-month refill, 3-month refill, e.t.c

Medication Details (Drug 6)

name of medication

e.g 2 tablets daily

e.g 500mg

1-month refill, 3-month refill, e.t.c

Medication Details (Drug 7)

name of medication

e.g 2 tablets daily

e.g 500mg

1-month refill, 3-month refill, e.t.c