Join the Alliance

Selected Plan:

Alliance Travel

$99.99/Annually

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First Name * Please enter your first name.

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Address 2

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Zip * Please enter a valid zip code.

Date of Birth * Please enter date of birth in mm/dd/yyyy format.

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Phone * Please enter phone number.

Membership Start Date * Please enter membership start date.

Note: Start date cannot be in the past or more than 60 days in the future.

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Agent Number * Please enter Agent Number.

Enter dependent information

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Note: Dependents age 19 to 28 must be full-time students.

Age requirements for some benefits may vary. You may list no more than 7 dependents.

Association Rx Card

You may choose dependents to be covered below.

Covered Family Members

(Member)

Program Participant

By enrolling in a plan, I authorize the Association, the Pharmacy Services Administrator and its participating pharmacies to share only information necessary to the fulfillment of prescriptions.

Member is required to pay the entire amount of the discounted rate. The purchase price may vary by drug and by pharmacy. Discounts are available only at participating pharmacies. No portion of the drug cost or dispensing fees for drugs purchased by members under this program is paid by Association Rx Card or EnvisionRxOptions. Pricing and tier positions are subject to change without notice. Pricing and tier positions are only for quantities stated; additional quantities may incur higher costs. May not be available in all states. Members may cancel the Association Rx Card program within thirty (30) days of joining the program, and shall be refunded any and all program fees paid during the initial program membership. Visit www.AssociationRXCard.com for more details on drug pricing and participating pharmacies. For additional information and assistance, please contact Alliance at 1-800-733-2242. This application is not a contract. For complete details, consult your fulfillment materials.

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