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Important Notice To Prospective Members!

Drugbenefit.com Is Offering You Access To A Prescription Benefit Program That Lets You Economically Obtain All Your Medications. And, Whether You Obtain Your Prescriptions Through Local or International Pharmacies, Your Patient-Protective Safety Measures Will Be In Effect. This Prescription Benefit Not Only Helps Save You Money When You Purchase Your Prescriptions, It Can Help You Manage Your Healthcare Costs.

In Addition To Direct Savings, You Will Receive These Valuable Services:

· COMPLETE, CENTRALIZED DRUG RECORDING (PROFILING) OF YOUR PRESCRIPTIONS

· ELECTRONIC SAFETY CHECKS FOR DRUG INTERACTIONS AND INCOMPATIBILITIES

· INFORMATION FOR YOUR PHARMACIST AND YOUR DOCTOR THAT CAN SAVE YOU MONEY

· IF YOU CHOOSE TO DIRECTLY IMPORT YOUR EXPENSIVE BRAND-NAME DRUGS, YOU HAVE NO-ADDITIONAL-COST ACCESS TO THE EXPEDITE-RX TECHNOLOGICAL INTERFACE IMPORT OPTION.

One year's participation in this one-of-a-kind benefit costs only $15.00 for individuals,

$25 for couples, and $5 for additional household members.

 

PRESCRIPTION BENEFIT ENROLLMENT FORM

 

Please complete and return with your check or credit card information to:

 

Drugbenefit.com

2801 W Avenue T

Temple, TX 76504

Fax: 800-810-3519*

Name _________________________________________________________ Sex: M or F (circle one)

Telephone Number: ___ ___ ___-- ___ ___ ___ --___ ___ ___ ___ DOB ____ /____ /____mm dd yy

Street___________________________________________ City _______________________________

State_______ Zip Code________________ e-mail _________________________________________

*Credit Card Information for Fax Orders: (Visa or MasterCard Only)

____________________________________ _________________________________________________

(Name on Card)                                                         (Card Number)                                              (Expires On)

 

(Rx benefit cards, instructions, and patient information will be mailed upon receipt of payment)