First American & Non-First American Spouse Prescription Program
To avoid any delays, please only send prescription requests once you have received approval of your application. Additionally, we kindly ask that you wait at least four business days after submitting your application before making any prescription requests.
Apply by Mail
1. Eligibility Form
The following form is required to verify eligibility for the program. Download, complete and return the form to the Chickasaw Nation Refill Center.
2. Notice of Privacy Practices (NOPP)
The Notice of Privacy Practices for the Chickasaw Nation Refill Center is a printable advisory for patients that explains the terms of use of patient-protected health information. This form is intended for patient use only and does not need to be returned to the pharmacy.
3. Acknowledgement of Receipt
The Acknowledgement of Receipt of Notice of Privacy Practices Form must be signed and returned to the pharmacy before any patient can be eligible to receive medications.
4. Provide Required Identification
- Certificate of Degree of Indian Blood (CDIB) (if applicable)
- Tribal citizenship card (if applicable)
- Prescription insurance card, front and back
- Secondary prescription insurance card, front and back (if applicable)
- Marriage license (if applying as a non-Native spouse)
- DL/state ID (Participants under 18 years of age need to have a parent or legal guardian’s valid ID on file)
Request Medications
Once your application is approved, submit your prescriptions to the Chickasaw Nation Refill Center for processing. Approved medications are provided to patients at no cost. When it’s time to refill your medications, you may use any of the convenient options listed below:
- Web Refill Patient Portal
- RefillPro smartphone application (iOS/Android)
- Call the pharmacy toll-free at 1 (855) 478-8725
Prescription Program Eligibility Information
All program participants require approval before receiving prescription assistance and requesting medications through the Chickasaw Nation Refill Center.
First Americans:
Once enrolled, participants may have prescriptions sent to the Chickasaw Nation Refill Center to be reviewed and processed. Completed prescriptions will be available to patients via mail or to be picked up in the drive-thru at the Chickasaw Nation Refill Center. As refills are needed, participants may call the Chickasaw Nation Refill Center directly or utilize our website, email, smartphone application or interactive telephone service to process refill requests.
All Participants Must Provide:
- Completed Application (each participant must submit a separate application)
- Copy of CDIB Card
- Copy of Tribal Citizenship Card
- Copy of Prescription Insurance Card (front and back of insurance card)
- Signed Acknowledgement of Receipt of Notice of Privacy Practices form
Non-First American Spouses:
All Participants Must Provide:
- Completed Application (each participant must submit a separate application)
- Copy of CDIB Card
- Copy of Tribal Citizenship Card
- Copy of Prescription Insurance Card (front and back of insurance card)
- Copy of Marriage License
- Signed Acknowledgement of Receipt of Notice of Privacy Practices form
Chickasaw Citizens Under 19 Years of Age:
All Participants Must Provide:
- Completed Application (each participant must submit a separate application)
- Copy of CDIB Card
- Copy of Tribal Citizenship Card
- Copy of Prescription Insurance Card (front and back of insurance card)
- Signed Acknowledgement of Receipt of Notice of Privacy Practices form
Non-Covered Items Include:
- Investigational Drugs
- IV medications and IV drug administration devices not covered by your insurance plan
- Over-the-counter (OTC) medications not covered by your insurance plan
- Compounded medications
All controlled substance medications must be picked up at the Chickasaw Nation Refill Center.
933 N. Country Club Road
Ada, OK 74820
Toll-Free: 1 (855) 478-8725
Local: (580) 421-8725
Fax: (580) 421-8701
