RxSavingsPlus™

^*Indicates a required field.

Gender^*

Male

Female

First^*

Initial

Last^*

Street Address^*

City^*

State^* Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip^*

Phone

E-mail^*

Birthday^* Month January February March April May June July August September October November December

 

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

This is NOT insurance. Discounts are only available at participating pharmacies. By using this card, you agree to pay the entire prescription cost less any applicable discount. Savings may vary by drug and by pharmacy. Savings are based on actual 2008 drug purchases for all drug discount card programs administered by CVS Caremark. The program administrator may obtain fees or rebates from manufacturers and/or pharmacies based on your prescription drug purchases. These fees or rebates may be retained by the program administrator or shared with you and/or your pharmacy. Prescription claims through this program will not be eligible for reimbursement through Medicaid, Medicare or any other government program. This program does not guarantee the quality of the services or products offered by individual providers. To cancel your participation in this program simply discard your ID card and notify your pharmacy that you are no longer participating in the program. We do not sell your personal information. Call the participant toll-free number on the back of your ID card to file a complaint related to the availability of contracted discounts, services or other contractual obligations of this program.
Note to Texas Consumers: Regulated by the Texas Department of Licensing and Regulation, P.O. Box 12157, Austin, Texas 78711; telephone 1-800-803-9202 or (512) 463-6599; Web site: www.license.state.tx.us/complaint.

Please select the Client associated with this enrollment.

Ask the applicant how they heard about RxSavingsPlus.

If the referring Client is not in the list, simply leave RxSavingsPlus selected.

The Applicant's Gender, First name and Last name are all required for this section.

If their Gender is not obvious, then simply ask them for their "Title". If they respond with "Ms." or "Mrs." please select "Female". If they respond with "Mr.", please select "Male".

The Applicant's full Address (including State, City and 5-digit Zip) are all required for this section.

The Applicant must also provide a valid phone number. Please enter all numerical values for the phone number.

A valid birthday is required from the Applicant for this section.

If the Applicant would like to register an existing card then please fill out this section.

Request the ID Number on the Card from the Applicant and enter it twice within this section.

Also request the "RxGRP" found on the Applicant's card and enter it below.

NOTE: Only valid RxGRP fields are accepted. If the Applicant has an RxGRP that appears invalid, please contact your administrator.