Account Activation

Activate Your Online Account

Please complete this form to activate your Xubex online account. Refills can be submitted through your Xubex account.You must be an existing patient to activate your account.

PLEASE NOTE:

This is not an order refill form. You can order your refills through your online account after it is activated or by calling customer service at (866) 699-8239.
Unique email account is required for each patient. Common email address can not be used to access multiple accounts.
Your online accounts can be activated only after your application is received and your prescriptions are processed.

Click here to login to your existing Xubex account

Account Activation Request Form

First Name:

Last Name:

Address:

City	State	Zip
Phone Number:	Date of Birth:(mm/dd/yyyy)	SS Number:(xxx-xx-xxxx)

Email Address:

Verify Your Email Address:

Comments:

Activate my Xubex account. By submitting this form, I certify that the information provided is correct and authorize the release of all information to the plan administrator.

*Indicates required information