AllianceRx: Online Refill Form

Once you have enrolled and sent your original prescription to AllianceRx and it has been filled once, you may have it refilled by submitting the online form below. Phone refills are available through the AllianceRx Refill line by calling 513-584-2323. Prescription(s) will be mailed to the address listed on your enrollment form.

Want to find out more about AllianceRx: Mail Order and how it works? See our Learn About AllianceRx section.

Want to find out about other cost-saving ideas? See our Cost Saving Ideas section.

Please fill out the following information for the prescription you want to refill.
*Click here for help on where to find Plan information
Health Alliance Select Plan Identification Number*	Associate's Name*
Select your Facility --Select a Location-- Fort Hamilton Hospital Jewish Hospital St. Luke Hospital East St. Luke Hospital West University Hospital Other Facility	Please supply a day time phone number.
Prescription information
Patient's Name	Patient's Member Number* (as found on your Select Plan Membersip Card) Select the member's number 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15
Rx Number	Drug Name
Rx Number	Drug Name
Rx Number	Drug Name
Rx Number	Drug Name
Rx Number	Drug Name
Rx Number	Drug Name
*Click here for help on where to find Plan information