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Nationwide DMPO Disclosure for Free Coupon Programs

THIS Coupon Program IS NOT INSURANCE and is not intended to replace health insurance.

This coupon program does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00. This coupon program is not a Qualified Health Plan under the Affordable Care Act. THIS IS NOT A MEDICARE PRESCRIPTION DRUG PLAN.* This coupon program does not make payments directly to the pharmacies. Discounts are only available at participating pharmacies. By using this card, you agree to pay the entire prescription cost less any applicable discount. Savings may vary by drug and by pharmacy. Coupon program members are obligated to pay for all prescriptions but may receive a discount from those pharmacies which have contracted with the coupon program. The program administrator may obtain fees or rebates from manufacturers and/or pharmacies based on your prescription drug purchases. These fees or rebates may be retained by the program administrator. Prescription claims through this program will not be eligible for reimbursement through Medicaid, Medicare or any other government program. This program does not guarantee the quality of the services or products offered by individual pharmacists. We do not sell your personal information. Call the member toll-free number on the back of your ID card to file a complaint related to this program. Note to Texas Consumers: You may contact the Texas Department of Insurance if you remain dissatisfied after completing this program's complaint process. You may access a list of participating pharmacies at: http://www.nebraskarxcard.com/pharmacy.php. Upon request the coupon program will make available a written list of participating pharmacies. Discount Drug Coupon Program Organization and administrator: United Networks of America, Inc., 3636 S. Sherwood Forest Blvd, Sherwood Tower 440, Baton Rouge, Louisiana 70816. Toll free phone number: 1-800-726-4232. This program is not available in Arkansas, Montana, and Vermont.

*Medicare statement applies to MD residents.