Buena Vista Pharmacy Card

Case Information

If you do not have this information yet or it is not applicable, you can type "Unknown" or "N/A" in any field
Injury date *

Month Day Year
01/05/2018
Case type
Liability
Property damage
Total medical bills
(not including prescriptions)
Policy limits

Card Controls
Maximum Card Limit *
*TOTAL NEW Limit - Not just the amount to increase*
Expiration Date *

Month Day Year
*New Feature*

Prescription Coverage Options:
- Cover pain/inflammation prescriptions - Pain, inflammation, triptans, SSRi's, muscle relaxants, PPI's, antibiotics, and other likely injury or related medicines will be covered by default. All other medications will be rejected unless added to coverage.
- Cover any prescription - No restrictions, all drugs are covered by default.
Prescription Coverage *

Cover pain/inflammation prescriptions Cover any prescription

Submit Form
***IMPORTANT UPDATE***

The Pharmacy Card Program now only covers prescription generic pain and inflammation medications.

If you or your client is trying to fill: Over the counter, Name Brand, Non-pain, or Non-inflammation medications, please enter the Drug Name and Strength (e.g., Valium 5mg) to the 'Comments' section below.

You can also upload a copy of the prescription below or call ahead (844) 796-3322 include non-approved medications to the Pharmacy Card.
Comments

For special instructions, notes, or comments. 0/249
Upload prescription

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