Wiley’s Prescription Discount Club

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Save on prescriptions and join Wiley's prescription discount club

Start Saving More…Today!

Are you without prescription drug insurance or don’t have enough prescription insurance? You could pay only $16 for a 90-day supply of prescription or over-the-counter (OTC) medicine.

Wiley’s Pharmacy now offers a prescription club program that allows you to get medicine in a 30-day or 90-day supply. You will also have access to savings on over 5,000 prescriptions and generic medications. In addition, you have options to pay a flat rate on over 300 generic drugs, have coverage on certain immunizations, and access to some pet medications. See the list of medications below.

Joining Wiley’s Prescription Discount Club is easy! Simply download the form below, complete it, and take it to your closest Wiley’s Pharmacy or submit it online. Once you are entered into the system, there is a $10 yearly subscription fee that’ll be added to your first prescription. This subscription fee covers your whole family and only needs to be paid once a year. From there, you can choose to get a 30-day supply of your medication for $6 or a 90-day supply for $16 if it is listed under the flat rate list.

Enroll Now Wiley’s Prescription Discount Club Details >

Patient Enrollment Form Prescription Club Generics List

Wiley's Discount Club Enrollment Form

Subscriber Information

First Name*

Middle Initial

Last Name*

Date Of Birth*

Address*

City*

State*

Zip*

Phone Number*

Email Address*

*Required fields

SUBSCRIBER-COVERED DEPENDENTS

Dependent 1:

First Name

Middle Initial

Last Name

Date Of Birth

Relationship

Dependent 2:

First Name

Middle Initial

Last Name

Date Of Birth

Relationship

Dependent 3:

First Name

Middle Initial

Last Name

Date Of Birth

Relationship

Add Dependent

Terms:

This pharmacy savings program, the Wiley’s Prescription Discount Club, is administered by Medical Security Card Company, LLC (MSC) of Tucson, Arizona. In administering the Prescription Club program, MSC receives protected health information (including but not limited to the information provided on this enrollment form) from Prescription Club transactions submitted by participating provider pharmacies or directly from you. Your authorization is required as a condition of enrollment in Prescription Club program as MSC must have this information to administer its point-of-sale discount service. The protected health information provided to MSC and any provider pharmacy for purposes of administration of the Prescription Club program is not transferred, sold or otherwise disclosed to third parties, except as necessary for the proper administration of the Prescription Club program, or as may be otherwise required by law, and is always protected as Confidential Private Information. For additional information, including the Notice of Privacy Practices for participating providers, please visit www.myleaderprescriptionclub.com. To view the MSC Privacy Policy, please visit: www.scriptsave.com/Terms.

Authorization:

I understand that my signature on this enrollment form constitutes my written authorization for MSC to receive and use the protected health information described above for the proper administration of the Prescription Club program in accordance with applicable law. I understand that if my medical information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by a person who receives my medical information and this re-disclosure may not be protected by the applicable privacy laws. This authorization shall remain in effect for the duration of my enrollment in the Prescription Club. I have the right to revoke this authorization in writing at any time by contacting Medical Security Card Company, LLC at 4911 E. Broadway Blvd., Tucson, AZ 85711, except to the extent that my medical information has already been used or disclosed in reliance on this authorization. However, because this information is essential to the administration of this program, my revocation of this authorization shall result in cancellation of my enrollment in the Prescription Club program.

I have read and authorize the above.*

Additional Health Savings Information: Pursuant to your enrollment in the Prescription Club, MSC and your pharmacy may also provide you with special information to enhance your health, such as drug price comparisons, and/or special savings opportunities (Additional Health Savings Information) through programs administered by MSC and/or pharmacy. Your signature below constitutes your written authorization for MSC and your pharmacy to provide you with Additional Health Savings Information by regular mail or by email at the addresses indicated above. You may opt out of receiving future transmissions of Additional Health Savings Information by contacting your participating pharmacy. If you are signing on behalf of dependent family members, your signature verifies that you are the parent/legal guardian or the authorized representative of the individuals identified above.

I have read and authorize the above.*

I understand that I have a right to receive a copy of this signed authorization upon request.*

THANK YOU!

YOUR PRESCRIPTION CLUB ENROLLMENT HAS BEEN SENT!

Your Wiley’s Pharmacist will contact you to finalize your enrollment into our prescription discount club. In the meantime, see what else Wiley’s has to offer.

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