Pharmacy Home Delivery

Pharmacy Home Delivery

P.O. Box 668
Roswell, GA 30077

Customer Service: (800) 862-1456
Toll Free Fax: (888) 805-2406

Free Savings Evaluation

Fill out this form to receive a free drug
savings evaluation and to see if you qualify
for assistance with Medicare Part D.

Your Information

If you want to know if you qualify for any extra help
in paying for your drugs, include your total household
income and marital status in the comments section.

Insurance Information

Medicare:

Medicaid:

Private Ins.:

Drug Card:

Copays:

$

$

$

Diabetic:

Brand of Meter:

Drug Details

Name of Drug Drug
Strength
(mg)
Pills/
Day
Your Cost
30 Days Supply
Is Your Cost
a Co-pay


Note: If more than 20 drugs, please send second form.