ENROLLMENT FORM
CHECK YOUR ELIGIBILITY
Please read the following list of eligibility requirements. If you meet all three requirements, check Yes below to continue.Questions? Call us at 1-800-444-4106.
  1. I have no prescription drug coverage of any kind.
  2. I am not eligible for Medicare.
  3. I have household income equal to or less than:
- $45,000 for a single person
- $60,000 for a family of two
- $75,000 for a family of three
- $90,000 for a family of four
- $105,000 for a family of five
Families of six or more and residents of Alaska and Hawaii should contact TogetherRx Access at
1-800-444-4106 for household income information.
Yes, I meet all of the eligibility requirements listed above.
YOUR INFORMATION

First Name
M.I.
Last Name

Address

City
State
Zip Code
- -
Telephone 		Select Date
Date Of Birth ( mm/dd/yyyy)

Email Address (optional) 		Yes, I'd like to receive Program updates via email.
MAY WE CONTACT YOU?
By checking YES, you agree that Together Rx Access and its business partners may contact you about new programs and services, additional product and health information or for market research purposes. 		Yes  No
How did you hear about the Together Rx Access Program?

SPOUSE OR DEPENDENTS: You may enroll additional family members in the Together Rx Access Program if: 1) you can claim them as financial dependent on tax returns or other government programs; 2) they are not eligible for Medicare; 3) they do not have other prescription drug coverage and 4) they are a legal US resident. If you have a spouse and/or dependent who meet this criteria, please click Add Dependents button.
If you are married, do you consider your spouse a dependent? Yes     No
How many dependents do you want to add?



PROGRAM INFORMATION
ENROLLMENT
I understand that the Administrator of the Together Rx Access Program will review my enrollment form, determine my eligibility, and notify me based on the information I provide. The Administrator may at any time require additional information to determine or confirm my eligibility. If I am eligible, I will receive a membership packet and Card by mail.

LIMITATIONS
Savings under the Program do not apply to prescription products reimbursed under any federal or state program, including Medicare or Medicaid ("Government Program"), or any private insurance, HMO, Medigap, employer, or other third-party arrangement ("Private Insurance"). By signing the enrollment form, I certify that I am not eligible for Medicare, and I do not have prescription drug coverage through any Government Program or private insurance.

The Card may be used only for outpatient prescription products included in the Program. Participating companies independently determine which products to include and the savings offered. Products and savings may change at any time. The Card may not be used with other prescription discount cards or pharmacy coupons. Coupons redeemed directly by a participating company are subject to the terms and conditions of the coupon.

The Card is valid only in the U.S. and Puerto Rico. The Program may be terminated or modified at any time.
AUTHORIZATION TO USE AND DISCLOSE INFORMATION
I understand that Together Rx Access and the Administrator of the Program will receive information about me and the prescription products that I receive using the Card. I authorize Together Rx Access to:

- use that information to administer the Program and to communicate with me.
- share that information with participating companies for market research or analysis.

Together Rx Access does not provide/sell personal information to third party companies not associated with the Program.

I may revoke this authorization by ending my participation in the Program by writing to Together Rx Access at the address provided in my membership packet.
IMPORTANT:By clicking the "Submit Request " button below, I certify that my spouse (if applicable) and I have read and understand the program information on this form. Additionally, I certify that the information on this enrollment form is accurate and complete. I understand and agree that an Administrator of the Together Rx Access program may contact me in the future to verify this information.