Date of Birth(mm/dd/yyyy)
Last 4 digit of your SSN:

Name Brand

HH Last Name	HH First Name	Relationship	Specialty Drug Indicator	Drug Tier Level Description	Drug Product Name	Member First Name	Member Last Name	NPI Last Name	Incurred Date	Allowed	Out of Pocket	Empid	HHID

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Generic

HH Last Name	HH First Name	Relationship	Specialty Drug Indicator	Drug Tier Level Description	Drug Product Name	Member First Name	Member Last Name	NPI Last Name	Incurred Date	Allowed	Out of Pocket	Empid	HHID