PrescriptionBenefitManagement.com
Free
Rx Drug Card For Brand and Generic Medication
Print off this page and use immediately!
·
Free! –
Can be used by your entire family. Cannot
be used in conjunction with any other pharmacy plan or discount. Save up to 50% using our program!
·
Acceptance
– Over 40,000 pharmacies including Walgreens,
ACME, Albertsons,Bi-Mart, Bioscrip,
Brooks, Buehler, Carr, Coborns, CUB, CVS, Dillon,
Discount Drug Mart, Dominicks, Drug Town, Duane Read,
Eckerd, Epic, Family Fare, Farm Fresh, Food City, Fred Meyer, Fred’s
Pharmacy, Fry’s, Giant Eagle, Glen’s, Harris Teeter, HEB, Hy-Vee, K-Mart, Kroger, K-VA-T Foods, Longs Drug Store,
Marc’s, Medicap, Medicine Shoppe, Meijer, OSCO, Pmida, P&C
Foods, Publix, Quality Markets, Randalls,
Rite Aid, Safeway Supermarkets, SAV-ON, Seaway, Shop & Save, Shopko, Shop-Rite, Smiths Pharmacies, Snyder Drug, Spartan
Drugs, Star Pharmacies, Stop & Shop, Super D, Target, The Pharm, Third Party Station, Tom Thumb, tops, USA Drug, USA
Express, Vons, Walgreens, Wal-Mart, Weis Market,
Winn-Dixie.
Please print this form and present
it to your pharmcist. Fill in the member name and ID
number before using. This card sheet can
be used immediately!
Name:
_____________________________________
ID/SS #: ___ ___
___ ___ ___
___ ___ ___ ___
(SS# or any random 9 digit number)
Pharmacist Instructions:
Process claim through Pharmacy Data Management (PDM)
Processor ID/BIN#: 610020
Processor Control #:URX001
Rx Plan Group #: WHS-2113
Pharmacy Help Desk: 1-800-329-0988 (pharmacist only)
Customer Service For Members: 1-540-777-7179
Terms and conditions: Participating pharmacies must transmit
prescription claims online to Pharmacy Data Management.
This card is not insurance.
For inquires on electronic
claims submission, pharmacies may call 1-800-329-0988.
This card is owned by U-Rx
program. U-Rx may revoke, repossess,
modify or cancel at any time. Use of
this card constitutes acceptance thereof.
The unauthorized or fraudulent use of this card to obtain prescription
drugs is punishable by law. The person
named on this card assumes responsibility for the use of the card.