YYYY MiRx Card
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MiRx Application Enrollment Form Last Name _______________________________________ First Name _____________________________ Middle Initial __________ Date of Birth (MM/DD/YYYY) ______ / ______ / ______________ Home Phone ( _________ ) _________ — __________________ Street Address _______________________________________________ P.O. Box _______________ Apt. Number _______________ City ______________________________________________ State ___________________________ Zip Code __________________ Last Name First Name MI Date of Birth (MM/DD/YYYY) Other Household Members (Attach __________________________ ______________________ ________ ______ / ______ / ____________ names and birth dates __________________________ ______________________ ________ ______ / ______ / ____________ of additional family members, if needed.) __________________________ ______________________ ________ ______ / ______ / ____________ I certify that my family meets the income limit for the MiRx discount card and we have no other prescription drug coverage. Sign: _________________________________________________________________________ Date: ___________________________ Your enrollment form is not complete unless it is signed. If you can not sign, a representative may sign for you. Please return your completed enrollment form to: MiRx Enrollment, P.O. Box 30479, Lansing, MI 48909 Michigan’s Prescription Drug Discount Card (MiRx) MiRx Enrollment P.O. Box 30479 Lansing, MI 48909 The Michigan Department of Health and Human Services will not exclude from participation in, deny beneÿts of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility. MDHHS-Pub-1361 21-0402 Michigan’s Prescription Drug Discount Card INTRODUCING THE MiRx Card
Transcript of YYYY MiRx Card
MiR
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I cer
tify
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my
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limit
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he M
iRx
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Your
enr
ollm
ent f
orm
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ot c
ompl
ete
unle
ss it
is si
gned
. If
you
can
not s
ign,
a re
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enta
tive
may
sign
for y
ou.
Plea
se re
turn
you
r com
plet
ed e
nrol
lmen
t for
m to
: MiR
x En
rollm
ent,
P.O
. Box
304
79, L
ansi
ng, M
I 48
909
Mic
hig
an’s
Pre
scri
ptio
n D
rug
D
isco
unt
Card
(M
iRx)
MiR
x En
rollm
ent
P.O
. Box
304
79La
nsin
g, M
I 489
09
The
Mic
higa
n D
epar
tmen
t of
Hea
lth a
nd H
uman
Ser
vice
s w
ill n
ot e
xclu
de
from
par
ticip
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y b
eneÿ
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of, o
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iscr
imin
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agai
nst
any
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oup
bec
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sex
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ge, n
atio
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rigin
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t, m
arita
l sta
tus,
par
tisan
con
sid
erat
ions
, or
a d
isab
ility
or
gene
tic in
form
atio
n th
at is
unr
elat
ed
to t
he p
erso
n’s
elig
ibili
ty.
MD
HH
S-P
ub-1
361
21-0
402
Michigan’s Prescription Drug Discount Card
INTRODUCING THE
MiRx Card
The MiRx Card — Michigan’s Prescription Drug Discount Card
The MiRx card is a simple and easy way to help my family cover all of our prescriptions.
We typically pay about 20% less per month using the MiRx card. The registration was simple and now all I do is hand the card to my pharmacist with our prescriptions and we automatically get the discount.
Hey, the MiRx card is free, but the beneft we get every month is priceless!
What is the MiRx Prescription Card Program?
˜e MiRx card is a way for Michigan residents who do not have prescription drug coverage to get their medication for less money at participating pharmacies.
Who is eligible? ˜ere is no age limit to participate. Eligibility must be established for each family member. To be eligible you must:
• Be a resident of the State of Michigan • Have no other prescription drug coverage • Have an income level at or below the state’s median
income level
Size of MI Median Family Unit Income
1 $ 53,113 2 64,428 3 78,217 4 93,653
Size of MI Median Family Unit Income
5 $ 102,653 6 111,653 7 120,653 8 129,653
April, 2021
How much less will I pay for prescription drug coverage?
When you present your MiRx card at participating pharma-cies you can expect to save about 20 percent o° the retail price of common prescription drugs. Savings will typically be between 5 and 25 percent, depending on the prescription drug and whether it is generic or a brand name.
The MiRx card is easy to use Take your prescription and your MiRx card to your pharmacy. Participating pharmacies will be listed on the Michigan Department of Health & Human Services web site (www.michigan.gov/mdhhs). Give the pharmacist your MiRx card and prescription. ˜e pharmacist will fll the prescription and charge you the discounted price. You will be expected to pay for the medicine at the discounted price. Always show your card for reflls.
Are all drugs covered? ˜e discount is good on any medicine the pharmacist stocks and your doctor prescribes. Over-the-counter drugs are not covered even if they are prescribed by your doctor.
It’s FREE ˜ere is no cost for the card or to enroll in the program. You just pay the discounted price to the pharmacy.
Why should I get the MiRx card? If you don’t have coverage, you will pay less for your medicines if you have an MiRx card.
Pharmacies can charge di°erent prices for the same medicines. With the MiRx card, you will be able to get your prescription medication at a lower price.
Who is sponsoring this program? ˜e program is sponsored by the State of Michigan. ˜e MiRx card was developed to provide prescription drug discount coverage programs for uninsured and under insured Michigan residents.
How can the State of Michigan get the discount?
˜e State has negotiated a discount on the prices with pharmacies. ˜ese prices are lower than the retail prices that you would pay as a cash customer. ˜e lower prices are made available to you when you show your MiRx card to participating pharmacies.
How can I apply for the program? Each family member or member of a household must be enrolled in the program. Each applicant will receive their own MiRx card. All eligible members of a family or household should be included on the enrollment form.
• Fill out the application (on the back of this brochure) and mail it to:
MiRx Enrollment P.O. Box 30479 Lansing, MI 48909
• If you have questions, call the MiRx Enrollment Hotline at 1-866-755-6479
• Copies of the MiRx application can be downloaded from the MiRx web site or you can fll out an application form online: https://mihealth.org/mirx
Once the application is completed and processed, Magellan will mail your card to you along with a list of participating pharmacies in your area. You will receive your card in two to three weeks.
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