Monthly Auto Refills
Have you ever forgot to request a prescription refill causing you to be out of your much needed medication? If you want to make sure this never happens to you, enroll in our Auto Refill Program. When you particpate in the Payless Pharmacy Auto Refill Program, your monthly prescriptions are automatically refilled on the same day each month. You can choose to pick up your prescription at one of our convenient locations or have your prescription delivered FREE directly to your home or workplace*.

Please use our form to request for Monthly Auto Refills for your prescriptions.

* = Required Information
Which pharmacy location fills your prescriptions? *
Pick Up Date - Time *
Not Set
Pick UpDelivery
Delivery Address *
City *
Zip Code *
Personal Information
Let us know a little about you and how we can contact you.
First Name *
Last Name *
Date of Birth *
Zip Code *
Phone # *
Yes, I want my monthly prescriptions to be automatically refilled when it is due.

Please list the medications that you want on Autofills in the comment section below if you know the names. If not, no problem, we will take care of it.
Your Rx Information
List your Rx numbers that you would like to setup for Auto-Refill.
Rx Number(s) to Auto-Refill:
Rx #
Rx #
Rx #
Rx #
Would you like us to notify you when your prescription(s) are ready?
Let us know if you have any special requests or provide any information that will assist us in processing your Auto-Refills
Security Code *