• View Card FAQ
  • Contact Us

  • Find a Pharmacy
     
    1.
    2.
    3.
     

    "My monthly prescription bill dropped from $105 to $84. We don't have health insurance, and this is savings we can use—without a monthly card fee." -D. Peterson

    Please fill out the form below to receive your temporary Prescription Savings Card. Please review the FAQ section for additional information.

    All bold items are REQUIRED fields and must be filled out.

    Group Code:
    First Name:
    Last Name:
    Middle Initials:
    Phone Number:
    E-Mail:
    Address:
    Address 2:
    City:
    State:
    ZIP Code:
    Birth Date: Month: Day: Year:
    Gender:
    Note: This card will work for your entire family, you do not need to fill out multiple forms for each family member.

     


    © 2004 DestinationRx, Inc., All Rights Reserved.