TIERED PRESCRIPTION DRUG PLAN                                  Enrollment Form
This program is accepted at over 50,000 participating pharmacies nationwide, including all the leading national chains! Simply visit a participating pharmacy, present your membership card and pay the pharmacy directly. Members have the potential to save thousands of dollars annually on the member’s prescription charges.

Tier 1 Drugs at up to a $10.00 maximum cost.*
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Tier 2 Drugs at up to a $20.00 maximum cost.*
Tier 3 All other Drugs are available for your benefit at negotiated rates. Your program also provides additional options to lower your cost on Tier 3 drugs through an independent mail order service** or free drug program.***
*Drugs are subject to be added or deleted without notice. A nominal handling fee may apply.
**Optional usage through an independent mail order service. ***Free drug programs available for pre-qualified low income families directly through drug manufacturers when and where available.
NOTE: Prices on Tiers 1, 2 & 3 are based on a 1 pill per day dosage, 30 day supply. Discount is only available at participating pharmacies. Please see prescription drug member guidebook for complete information and drug listings by Tier.