MyRxSAVINGS DISCOUNT DRUG PLAN
Immediate Savings on Prescription Drugs
• Over 11,000 Prescription Medications Discounted
• Accepted at over 54,000 Pharmacies Nationwide
including Safeway, Longs, Costco,Walgreens, OSCO,
CVS, Rite Aid .and more
THE S.O.S. PRESCRIPTION DRUG DISCOUNT PLAN
• Guaranteed Enrollment – NO Health Questions Asked
"America's Lifeline to Lower Cost Prescription Drugs"
• NO Pre-existing Conditions Limitations
• NO Deductibles, NO Monthly or
Annual Benefit Maximums
• NO Age Limits
HOW DOES THE MyRxSAVINGS DISCOUNT
DRUG PLAN WORK?
• Semi-Annual Proof of Savings Report
• 100% Satisfaction Guaranteed
MyRxSavings is an American company helping fellow Americans
to obtain prescription drugs at a substantial discount from retail
prices.The MyRxSavings Prescription Discount Card is accepted
SAMPLE PRESCRIPTION DRUG TIERS
at over 54,000 pharmacies throughout the United States including
Tier cost levels are based on strength, dosage and quantity
all of the major chain stores such as Safeway, Long's, Costco,
TIER 1: (Up to $10.00) Generic Drugs
TIER 1: (Up to $10.00)
Walgreen's, CVS, Rite Aid, OSCO,Thrifty Drugs, etc.There
are no pre-existing conditions, no health questions asked, no
deductibles, no monthly or annual maximum and there is no
age limit.This is not an insurance plan but a discount drug plan
that is managed and designed by pharmacists to help save you
TIER 2: (Up to $20.00)
money on your prescription drugs.
Ampicillin Sulfate Diflucan
This may sound too good to be true but the proof is in the
savings.You will receive a proof of savings report which will
be mailed to you twice a year documenting the savings realized
by using the MyRxSavings Discount Card. 100% Satisfaction is
TIER 3: (Up to $50.00)
Guaranteed! Use the Discount Card for 30 days and if you are
not completely satisfied, we will promptly refund 100% of your
initial access fee.
The MyRxSavings Discount Card covers in excess of 11,000
TIER 4: (Discount)
prescriptions. If you have questions concerning your prescription,
please contact the Pharmacy Benefit Manager at 1-800-546-5677.
■ Telephone: 800-948-2332
■ Facsimile: 800-876-9295
■ E-mail: firstname.lastname@example.org
■ Website: www.myrxsavings.net
This is NOT an insurance plan of coverage.
PRESCRIPTION DRUG COST TIERS
WHAT DISCOUNTS CAN I EXPECT UNDER THIS PROGRAM?
MyRxSAVINGS ENROLLMENT FORM
Discounts on individual prescriptions vary.Typically, the discounts
A.Tell Us About Yourself
will range from 13% to 60% off manufacturer's suggested retail
You pay $10.00 or less per prescription
price.What is unique about the program is the 4 Tier price list.
For most generic drugs, the maximum cost is $10.00 but at
times can be even less.Tier 2 drugs are set at a maximum cost
Telephone: ( ) -
You pay $20.00 or less per prescription
of $20.00 and Tier 3 drugs at a maximum of $50.00.The plan
design states "Up to the Tier Payment" which at times may be
less than the stated Tier cost providing you with further savings.
You pay $50.00 or less per prescription
* An email address is required if you want an immediate enrollment confirmation
and a temporary I.D. card.
HOW SOON CAN I ACCESS THE PHARMACY NETWORK?
The effective date of your enrollment into the program is the
B. Additional People to be Enrolled
Prescription drugs in Tier 4 are discounted from
day after MyRxSavings receives your application and your first
the suggested retail pharmacy price and can
month's payment. An email confirming your enrollment and
range from 13% to 60%
a temporary identification card will be emailed to you.The
Member Enrollment Kit with your permanent identification
100 days supply through mail order available at
cards will be mailed to you.
Monthly Access Fee:
additional discounts for maintenance drugs
Individual + Spouse:
IS THIS AN INSURANCE PLAN?
Individual + Child(ren): $15.95
FREQUENTLY ASKED QUESTIONS
No, this is not an insurance plan.The program is a pharmacy
A. Select your plan monthly access fee:
HOW CAN YOU FILL PRESCRIPTIONS AT SUCH COST SAVINGS?
network with over 54,000 participating pharmacies.
B. If you are prepaying more than 1 month, multiply
This program gives you similar pricing as to what the largest
the number of months by the monthly rate
insurance companies and HMOs receive through their bulk
ARE THERE ANY LIMITATIONS TO THE PROGRAM SUCH AS PRE-EXISTING HEALTH
(Semi-Annual = x 6, Annually = x 12)
purchasing contracts.The difference here is that we eliminated
CONDITIONS AND LIMITS TO THE AMOUNT OF PRESCRIPTIONS FILLED?
C. Add the one time enrollment fee of $10.00 or
much of the "administrative costs" in managing a discount
There are no pre-existing conditions and there are no monthly
enter Savings Code Number
prescription program.The program is managed by pharmacists
or calendar year maximum benefits. Furthermore, there is no
Total (A + C or B + C) =
and not by insurance executives.
age limit to participants in the program.
D. Member of a group or association sponsored plan
HOW DO I KNOW I AM REALLY RECEIVING THE DISCOUNTS YOU STATE
DO I NEED TO FILL OUT ANY CLAIM FORMS OR SUBMIT ANY PAPERWORK
FOR THE DISCOUNTS?
C. Select Your Payment Option
We will mail you twice a year a "Proof of Savings" report
No, there are no claim forms or any paperwork to fill out and the
For Semi-Annual or Annual Payments:
illustrating your actual savings by using our pharmacy network.
discounts are given at the time of purchase at the local pharmacy.
Attach a check made payable to MyRxSavings and mail to:
The report will show the manufacturer's suggested retail price
of your drug purchases versus your MyRxSavings discount price.
1009 Oak Hill Road, 3rd Floor
CURRENTLY HAVE A HIGH DEDUCTIBLE HEALTH INSURANCE PLAN.
Lafayette, California 94549
WILL THIS PROGRAM BE OF BENEFIT TO ME?
HOW CAN I DETERMINE WHICH TIER LEVEL MY PRESCRIPTION DRUG FALLS INTO?
Yes, most high deductible health plans do not have a discount
You can access our 4 Tier price list at our website located at
For Monthly Payments:
pharmacy benefit. You typically end up paying the maximum
www.myrxsavings.net. If you can not locate your medication, you
retail price for your prescriptions. Prescriptions filled under
can contact the Pharmacy Benefit Manager at 1-800-546-5677.
our program will be discounted and the costs may also be
eligible for deductible credits and count towards the plan's
I authorize MyRxSavings to charge the above credit card monthly for enrollment
financial out of pocket maximum.
into the MyRxSavings Discount Drug Program.
Signature: _ Date: _
WHAT IS THE 100% SATISFACTION GUARANTEE POLICY?
Use the MyRxSavings pharmacy discount card in the first 30 days
You can fax the completed enrollment form to our office at
(800) 876-9295 or mail to the address listed above.
and if you are not completely satisfied with the amount ofsavings, you will be refunded 100% of your initial access fee.
Marketing Use Only
Marketed By: Scott
Producer No.: MRX-1000-10079
Summary Care Records A QUICK REFERENCE GUIDE What is a Summary Care Record? When should I use the SCR? The Summary Care Record (SCR) is a ‘read only' electronic patient summary containing key clinical When dispensing an Times when you would information. It has been created with information emergency supply (at the want to ask the GP practice request of the patient)
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