COSTCO MEMBER PRESCRIPTION PROGRAM ENROLLMENT FORM WHY JOIN? The Costco Member Prescription Program provides qualified Costco members lower costs on prescription drugs. By enrolling in the program, Costco members who either have no available insurance coverage for medications or who have insurance, but their insurance does not cover all of their prescriptions, may pay less for certain prescriptions than what they would otherwise pay at a Costco Pharmacy for the same drug or a therapeutically equivalent alternative drug. NAME COSTCO MEMBERSHIP NUMBER DATE OF BIRTH PHONE NUMBER ADDRESS WHO IS ELIGIBLE TO JOIN? Enrollment in the program is open to those Costco members (and their dependents) who either have no prescription drug coverage available or who are insured but their insurance does not cover all of their prescriptions. Any uninsured participant who later obtains any form of prescription drug insurance must inform Costco, and his or her participation in the program will be canceled, except to the extent such insurance does not cover any of their prescriptions. Any individual who receives benefits from a publicly funded healthcare program, such as Medicare or Medicaid, is not eligible. HOW MUCH WILL I PAY? There is no additional charge for Costco members to participate in the Costco Member Prescription Program. Customers who are not members of Costco must join Costco at any membership level to participate in the Program. Costco membership provides many benefits including the ability to benefit from value-added services such as the Program. HOW MUCH WILL I SAVE? Beginning with your first prescription after enrollment, the amount of any price reduction is determined at the time of purchase, based on financial arrangements with manufacturers and suppliers regarding the drug(s) dispensed, and/or on Costco’s net cost of purchasing certain drugs, both of which may change from time to time. Savings are estimated between 2% and 40% off and calculated at the time of sale. You are welcome to ask your pharmacist about the amount of your savings under the program when you purchase a prescription. You also may provide your pharmacist with another drug discount card or program and ask whether that card or program would provide greater savings than the Costco Member Prescription Program. During the initial implementation period, customers who lack insurance may have access to program pricing on a one-time basis without having enrolled. IS THIS PROGRAM AVAILABLE AT ANY COSTCO PHARMACY? Costco Member Prescription Program Name: Member ID#: # # # # # # # # # # # # # # # # # This program is only available at Costco. The Costco Member Prescription Program is NOT insurance. Member inquiries, call 1-800-806-0129. PLAN# 11111 BIN:009893 PCN:AE02 The pricing available through the program applies only at Costco pharmacies located within the states in which the program is offered. For a list of participating Costco pharmacies near you and any member inquiries, please call Costco at 1-800-806-0129. Program Administrator: Envision Pharmaceutical Services, Inc P.O. Box 1298 Twinsburg, OH 44087 1-800-361-4542 CITY STATE SIGNATURE ZIP DATE PLACE PHARMACY BAR CODE HERE TO JOIN, please complete and sign the enrollment form above. By your signature, you acknowledge that you understand how the program works and the eligibility requirements, as noted below, and you agree and understand that: tT he program is NOT insurance and does not provide reimbursement for prescription drugs. t:PVSFMJHJCJMJUZUPQBSUJDJQBUFJOUIFQSPHSBNJTDPOEJUJPOFEPOZPVSMBDLPGQSFTDSJQUJPOESVHDPWFSBHF:PVDFSUJGZUIBUUIF individual named above (whether yourself or a dependent) either has no insurance or third party coverage for prescription drugs and supplies or has insurance but his or her insurance does not cover all of his or her prescriptions. t5IFQSPHSBNQSPWJEFTBMPXFSDPTUGPSQSFTDSJQUJPOESVHTXIJDINBZDIBOHFGSPNUJNFUPUJNF t%VSJOHUIFJOJUJBMJNQMFNFOUBUJPOQFSJPEDVTUPNFSTXIPMBDLJOTVSBODFNBZSFDFJWFQSPHSBNQSJDJOHPOBQSFTDSJQUJPO purchase before having enrolled in the program. No one may receive ongoing access to program pricing without enrollment. t1SPHSBNQSJDJOHNBZOPUCFDPNCJOFEXJUIPUIFSEJTDPVOUTPSQSPNPUJPOTBOENBZOPUBMXBZTCFMPXFSUIBOXIBUZPV would pay for an equivalent drug using another drug discount card or program. To take advantage of lower prices under other discount cards or programs, you must present the card or program information to the Costco pharmacist at the time of your purchase. t5PQSPWJEFNBYJNVNTBWJOHTVOEFSUIFQSPHSBNZPVS$PTUDPQIBSNBDJTUNBZOFFEUPTVCTUJUVUFBEJGGFSFOUUIFSBQFVUJDBMMZ equivalent drug for the one your doctor prescribed. From time to time, Costco may provide you with personalized information about these savings opportunities either by mail or through your pharmacist at the time of purchase. These substitutions will begin after the initial enrollment period. t:PVBVUIPSJ[FUIF$PTUDPQIBSNBDJTUUPTVCTUJUVUFBUIFSBQFVUJDBMMZFRVJWBMFOUESVHQSPWJEFEUIBUUIFTVCTUJUVUJPOJTB permitted by the prescription or specifically authorized by the prescribing physician; (b) consistent with state law and sound pharmaceutical practice; and (c) less costly than what you would have paid for either the original drug prescribed or another drug that could have been substituted under state law. In some instances, state law may require your pharmacist to substitute a generic or a specific brand drug unless you object to the substitution. By joining the program, you object to those mandatory state law drug substitutions if the drug that is required to be substituted would cost you more than the drug substitution available under the program. t*OGPSNBUJPOSFMBUFEUPZPVSQBSUJDJQBUJPOJOUIFQSPHSBNXJMMCFTVCKFDUUP$PTUDPT/PUJDFPG1SJWBDZ1SBDUJDFT t$PTUDPSFTFSWFTUIFSJHIUUPNPEJGZUIFUFSNTBOEDPOEJUJPOTPGUIFQSPHSBNBUBOZUJNFBOEGSPNUJNFUPUJNF$PTUDPNBZ terminate the program at any time, with or without any advance notice to program participants.