Any known, please list.
(ie. Brilinta, Ranexa, Multitaq, Carvedilol)
Include sample amounts and/or discount card information
(this would be on the card you would give to the pharmacist when you get your prescriptions refilled)
Please include the plan name, ID #, and Group #.
Please include the plan name, ID #, and Group #. (ie. Medicare PART A or PART B, Medicaid, etc.)
Many of the drug prescription assistance programs require proof of income.
Please indicate if this is a cell or home number.
Phone: (706) 208 9700 Mail: email@example.com