RxProtect - RxProtect Program Registration

Primary Email*

First Name*

Last Name*

Primary Phone*

Full Address*

What is the name/s of the medication/s you'd like to process through the RxProtect program?*

How much money out of pocket (copay and deductible) does the medication/s you are submitting through the RxProtect program cost you per year?

Upload a copy of the script if you have a physical copy. If not, please have your provider fax it to us at 917-909-5923.

All plans qualify.

All plans, including High Deductible Health Plans, qualify for immediate enrollment into the RxProtect program.

Pharmacy requires past medical history and allergies for the safety of medication interactions. Please complete. Thank you.*