Register - Specialty Pharmacy Co-Pay Portal

Facility Name

Facility NPI

Facility NCPDP

Facility Address

Facility Address Line 2

Facility City

Facility State

Facility Zip

Point of Contact First Name

Point of Contact Last Name

Point of Contact Email

Point of Contact Number

Please provide applicable user list in table format, including First and Last Name, Email, and NCPDP for portal access and submission of claims.

* Files must be excel, word, csv, or txt with a maximum size of 5MB each

Create Facility Account