ENROLLMENT
I understand that Together Rx Access has hired an Administrator to administer the Together Rx Access Program, who 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 submitting the enrollment form, I certify that I am not, nor are any of my family members listed on this application, eligible for Medicare, and I do not have prescription drug coverage through any government program or private insurance, nor do any of my family members listed on this application.
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 US 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 will receive information about me and the prescription products that I receive using the card. By submitting this application, I authorize Together Rx Access and the Administrator to:
- use that information to administer the Program and to communicate with me.
- share that information with participating companies for market research or analysis.
This authorization is in addition to any authorization that I have given under the heading May We Contact You? on the reverse side of this application. 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 the Together Rx Access Program at the address provided in my membership packet.