COSTCO MEMBER PRESCRIPTION PROGRAM ENROLLMENT FORM WHY JOIN?

COSTCO MEMBER PRESCRIPTION PROGRAM
ENROLLMENT FORM
WHY JOIN?
The Costco Member Prescription Program provides qualified
Costco members lower costs on prescription drugs. By enrolling
in the program, Costco members who either have no available
insurance coverage for medications or who have insurance, but
their insurance does not cover all of their prescriptions, may pay less
for certain prescriptions than what they would otherwise pay at a
Costco Pharmacy for the same drug or a therapeutically equivalent
alternative drug.
NAME
COSTCO MEMBERSHIP NUMBER
DATE OF BIRTH
PHONE NUMBER
ADDRESS
WHO IS ELIGIBLE TO JOIN?
Enrollment in the program is open to those Costco members (and
their dependents) who either have no prescription drug coverage
available or who are insured but their insurance does not cover all
of their prescriptions. Any uninsured participant who later obtains
any form of prescription drug insurance must inform Costco, and his
or her participation in the program will be canceled, except to the
extent such insurance does not cover any of their prescriptions. Any
individual who receives benefits from a publicly funded healthcare
program, such as Medicare or Medicaid, is not eligible.
HOW MUCH WILL I PAY?
There is no additional charge for Costco members to participate
in the Costco Member Prescription Program. Customers who are
not members of Costco must join Costco at any membership level
to participate in the Program. Costco membership provides many
benefits including the ability to benefit from value-added services
such as the Program.
HOW MUCH WILL I SAVE?
Beginning with your first prescription after enrollment, the amount of
any price reduction is determined at the time of purchase, based on
financial arrangements with manufacturers and suppliers regarding
the drug(s) dispensed, and/or on Costco’s net cost of purchasing
certain drugs, both of which may change from time to time. Savings
are estimated between 2% and 40% off and calculated at the
time of sale. You are welcome to ask your pharmacist about the
amount of your savings under the program when you purchase a
prescription. You also may provide your pharmacist with another
drug discount card or program and ask whether that card or program
would provide greater savings than the Costco Member Prescription
Program. During the initial implementation period, customers who
lack insurance may have access to program pricing on a one-time
basis without having enrolled.
IS THIS PROGRAM AVAILABLE AT
ANY COSTCO PHARMACY?
Costco Member
Prescription Program
Name:
Member ID#: # # # # # # # # # # # # # # # # #
This program is only available at Costco. The Costco
Member Prescription Program is NOT insurance.
Member inquiries, call 1-800-806-0129.
PLAN# 11111 BIN:009893 PCN:AE02
The pricing available through the program
applies only at Costco pharmacies located within
the states in which the program is offered. For a
list of participating Costco pharmacies near you
and any member inquiries, please call Costco at
1-800-806-0129.
Program Administrator:
Envision Pharmaceutical Services, Inc
P.O. Box 1298
Twinsburg, OH 44087
1-800-361-4542
CITY
STATE
SIGNATURE
ZIP
DATE
PLACE PHARMACY BAR CODE HERE
TO JOIN, please complete and sign the enrollment form above. By your signature,
you acknowledge that you understand how the program works and the eligibility
requirements, as noted below, and you agree and understand that:
tT he program is NOT insurance and does not provide reimbursement for prescription drugs.
t:PVSFMJHJCJMJUZUPQBSUJDJQBUFJOUIFQSPHSBNJTDPOEJUJPOFEPOZPVSMBDLPGQSFTDSJQUJPOESVHDPWFSBHF:PVDFSUJGZUIBUUIF
individual named above (whether yourself or a dependent) either has no insurance or third party coverage for prescription
drugs and supplies or has insurance but his or her insurance does not cover all of his or her prescriptions.
t5IFQSPHSBNQSPWJEFTBMPXFSDPTUGPSQSFTDSJQUJPOESVHTXIJDINBZDIBOHFGSPNUJNFUPUJNF
t%VSJOHUIFJOJUJBMJNQMFNFOUBUJPOQFSJPEDVTUPNFSTXIPMBDLJOTVSBODFNBZSFDFJWFQSPHSBNQSJDJOHPOBQSFTDSJQUJPO
purchase before having enrolled in the program. No one may receive ongoing access to program pricing without enrollment.
t1SPHSBNQSJDJOHNBZOPUCFDPNCJOFEXJUIPUIFSEJTDPVOUTPSQSPNPUJPOTBOENBZOPUBMXBZTCFMPXFSUIBOXIBUZPV
would pay for an equivalent drug using another drug discount card or program. To take advantage of lower prices under
other discount cards or programs, you must present the card or program information to the Costco pharmacist at the time
of your purchase.
t5PQSPWJEFNBYJNVNTBWJOHTVOEFSUIFQSPHSBNZPVS$PTUDPQIBSNBDJTUNBZOFFEUPTVCTUJUVUFBEJGGFSFOUUIFSBQFVUJDBMMZ
equivalent drug for the one your doctor prescribed. From time to time, Costco may provide you with personalized information
about these savings opportunities either by mail or through your pharmacist at the time of purchase. These substitutions
will begin after the initial enrollment period.
t:PVBVUIPSJ[FUIF$PTUDPQIBSNBDJTUUPTVCTUJUVUFBUIFSBQFVUJDBMMZFRVJWBMFOUESVHQSPWJEFEUIBUUIFTVCTUJUVUJPOJTB
permitted by the prescription or specifically authorized by the prescribing physician; (b) consistent with state law and
sound pharmaceutical practice; and (c) less costly than what you would have paid for either the original drug prescribed or
another drug that could have been substituted under state law. In some instances, state law may require your pharmacist
to substitute a generic or a specific brand drug unless you object to the substitution. By joining the program, you object to
those mandatory state law drug substitutions if the drug that is required to be substituted would cost you more than the
drug substitution available under the program.
t*OGPSNBUJPOSFMBUFEUPZPVSQBSUJDJQBUJPOJOUIFQSPHSBNXJMMCFTVCKFDUUP$PTUDPT/PUJDFPG1SJWBDZ1SBDUJDFT
t$PTUDPSFTFSWFTUIFSJHIUUPNPEJGZUIFUFSNTBOEDPOEJUJPOTPGUIFQSPHSBNBUBOZUJNFBOEGSPNUJNFUPUJNF$PTUDPNBZ
terminate the program at any time, with or without any advance notice to program participants.