✃
Please complete the following application
A Message from the
and mail along with membership fee to:
GSPO Provider Services Corp. Passaic County
P.O. Box 4190 Board of Chosen Freeholders
Hamilton, NJ 08610
The Passaic County Prescription
MEMBERSHIP APPLICATION
Please check one of the following:
Savings Card Program was created to
! 1 year membership $20.00 assist seniors and the disabled with
! 3 year membership $40.00 reducing the financial burden of
CARDHOLDER INFORMATION
prescription purchases.
Last Name: ________________________________ This innovative program, which has
First Name: ________________________________ been recommended by the Passaic
County Board of Chosen Freeholders,
Street: _____________________________________
is provided to our County taxpayers
CUT ALONG DOTTED LINE
City ST Zip: _______________________________
at a $20.00 annual registration fee (or
Phone: ____________________________________ a $40.00 registration fee for a full three
Birthdate: ______________Male/Female: _______ year membership) and will provide The
significant discounts on name brand
and generic drugs.
Passaic County
DEPENDENT INFORMATION
Prescription
Last Name: ________________________________
Toll-Free Customer Service: Savings
First Name: ________________________________
1-800-633-0037 Program
Birthdate: ______________Male/Female: _______
(For additional dependents, please attach sheet)
IMPORTANT
(PLEASE READ)
By signing below, I attest that the above persons: SONIA ROSADO
• The Prescription Savings Program is a discount
• are residents of Passaic County. Freeholder Director
savings card and not a managed care or a supplemental
• are not currently covered through any government insurance program.
sponsored or employer based prescription insurance TAHESHA WAY
program. • The Prescription Savings Program cannot be used in
combination with other programs for the same Deputy Freeholder Director
• understand that this is a discount savings program
prescription purchase.
and not a managed care, insurance or supplemental FREEHOLDERS:
insurance program. • The Prescription Savings Program membership fee is
• understand that this program cannot be used in non-refundable. PAT LEPORE
combination with other programs for the same JAMES GALLAGHER
prescription purchase. GSPO Provider Services Corp. TERRY DUFFY
P.O. Box 4190
Signature: _______________________________ BRUCE JAMES
Hamilton, NJ 08610
PLEASE NOTE: You must attach proof of County ELEASE EVANS
residency (copy of cardholder’s driver’s license or
recent utility bill) for your enrollment to be processed. WWW.GSPOPS.COM
The Passaic County Why should I apply Do I have to mail my prescriptions
Board of Chosen for this Program? away in order to receive my savings?
Freeholders • For a small annual membership fee, • No. Your Prescription Savings Card
is pleased to present you will receive a Passaic County is accepted throughout an extensive
the Prescription Prescription Savings Card which network of participating independent and
provides special discounted pricing on chain pharmacies in New Jersey and
Savings Program
prescription medications for all nationwide.
members of your household. • Save at pharmacies in town or across the
What is the Passaic County • You can save up to 10% to 50% off country.
Prescription Savings Program? regular retail prescription prices. • Mail order services are available.
• It is a program designed to provide What limitations apply to the
eligible residents of Passaic County with Prescription Savings Program?
savings of up to 50% on prescription
medications. • There are no quantity limits, receive as
much medication as prescribed.
Who is eligible ? • There are no limits on the number of pre-
• All residents of Passaic County and their scriptions you can fill or refill.
dependents (living in the same house- • There are no deductibles to meet.
hold) who are not currently covered
• There are no forms to fill out. How do I use the
through any government sponsored or
Prescription Savings Card?
employer based prescription insurance
program. • Present your Prescription Savings Card
to your pharmacy along with your pre-
Are there any other restrictions? scriptions to be filled.
• There are no age restrictions. • Your pharmacy will notify you of your
• There are no income requirements. special discounted price.
• There are no exclusions for pre- • You pay just this price!
existing conditions.
Do I have to change my medications How do I apply?
Is this insurance? in order to receive my savings? • Complete the attached application (on
• The Passaic County Prescription • No. All brand name and generic drugs the reverse of this panel).
Savings Program is NOT a managed which require a prescription under • Attach required proof of residency along
care, insurance, or supplemental insur- Federal and State laws are included; there with your membership fee and mail as
ance program. are no exclusions. indicated.