Print PDF Email Smartphone Users: Simply show this coupon to the technician during checkout from your internet browser.
We are currently working on a secure web enrollment program, but we would love to talk to you in the meantime.
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First Name:* Last Name:*
Email:* Phone Number:*
What type of household will be using the prescription plan?* ---Individual ($22/month)Couple ($32/month)Family ($42/month)
This form is for pre-enrollment only. Upon completion, we will contact you within 24 hours to finish your enrollment.I understand:*
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Submit your information below and one of our team members will contact you with program information specific to your needs.
Name of Organization:*
What type of organization is it?*---ChurchSchoolShelterFood BankThrift StoreClub/OrderOther
How did you hear about us? (optional)
Do you spend more than $80.00 per month, every month, on your prescription medications?* ---YesNo
Do you currently have any insurance or prescription coverage? * ---YesNo
Do you currently have Medicare/Medicaid?* ---YesNo