CARING RX PRESCRIPTION DRUGS PROGRAM
OUR PROCESS IS SIMPLE!
If you are paying more than $30 a month for each of your prescription medications, enroll today and start saving today with Caring Rx.
ONE PRESCRIPTION $30 SERVICE FEE
TWO PRESCRIPTIONS $60 SERVICE FEE
THREE PRESCRIPTIONS $90 SERVICE FEE
PATIENT INFORMATION
NAME
BIRTH DATE
SOCIAL SECURITY NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE)
PHONE NUMBER
EMAIL ADDRESS
FINANCIAL INFORMATION
ANNUAL GROSS HOUSEHOLD INCOME
Income and household size, including yourself and the number of people who live in your home and are dependent on your household income
PRESCRIPTION INFORMATION
MEDICATION NAME
STRENGTH, AND DOSAGE
HEALTHCARE INSURANCE INFORMATION
PRESCRIPTION INSURANCE/MEDICARE PART D PLAN
PRIVATE/COMMERCIAL INSURANCE
MEDICAID, MEDICARE PART B
VETERANS ADMINISTRATION
STATE PATIENT ASSISTANCE PROGRAM, ETC.
HEALTHCARE PROFESSIONAL
DOCTOR’S NAME
FACILITY NAME
ADDRESS (STREET, CITY, STATE, ZIP)
PHONE NUMBER
FAX NUMBER
PAYMENT INFORMATION
CHECKING OR CREDIT/DEBIT CARD ACCOUNT INFORMATION
FOR MONTHLY SERVICE FEE
WHO IS ELIGIBLE?
All applications are reviewed in accordance with Prescription Assistance Program eligibility criteria
You may be eligible for a prescription assistance program if you meet the requirements below
YOU LIVE IN THE UNITED STATES OR A U.S. TERRITORY.
YOU ARE BEING TREATED BY A U.S. LICENSED DOCTOR AS AN OUTPATIENT.
YOU MEET THE MEDICATION(S) ELIGIBILITY INCOME REQUIREMENTS.
YOU DON’T HAVE INSURANCE OR YOUR MEDICATION IS NOT COVERED.
Some clients with Medicare Prescription Drug Coverage (Part D) who cannot afford their medication and who meet certain financial criteria may also be eligible for assistance.
NOTE: MISSING INFORMATION AND/OR REQUIRED DOCUMENTS MAY DELAY PROCESSING OF AN APPLICATION.
