View Policy Cost
DRUG COVERAGE OPTIONS
This plan is not insurance. This is a co-pay discount card. Formulary may not be accurate and change quarterly.
- $25 Individual
- $35 Individual/Spouse/Children
Fully Insured RX copay plan This plan may not be available in all states.
Prefer to submit your application by Email?
Download the application below,
fill it out, and send it to firstname.lastname@example.org.