Liberty Benefits Online Application

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Primary Member

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Spouse or Partner

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Dependents

First Name	Middle Name	Last Name	Date of Birth	Gender

Shipping Address

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Same As Shipping Address

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Email Confirmation

Member agrees to receive email notifications from Liberty Benefits on policy changes.

Individual Plan

Please select which Plans you would like to enroll in.

Product	Monthly Fee	App Fee	Total
$30.00 Liberty Prescription Plan	$30.00	$30.00	$60.00
$50.00 Protector Plan	$50.00	$50.00	$100.00
$25.00 Legal Access Plan	$25.00	$30.00	$55.00

Liberty Prescription Plan, Protector Plan, and Liberty Legal Access Plan are available in all states.

Disclosures

I Agree *

I Agree with the disclosure below.

Click Here for Liberty Rx Prescription Plan

Rx Terms

LIBERTY RX PRESCRIPTION PLAN 30 DAY CANCELLATION POLICY

If a Member is not satisfied with the Liberty Rx Prescription Plan and wishes to terminate his/her plan, the Member may cancel the plan for any reason by notifying Liberty Benefits in writing, via fax or via the cancellation website. Members may call 877-867-5423 to obtain the fax number, cancellation website and mailing address. Cancellation requests received by Liberty Benefits during non-business hours will be processed the next business day. If a Member cancels within the first 30 days from the Plan Entry Date, the Member will be eligible for a full refund of the Plan and one-time registration fee. Refunds can take up to 15 business days to process from the date Liberty Benefits receives the notification of cancellation. If the Member cancels after the first 30 days, the Plan will terminate at the end of the Plan Term following the date Liberty Benefits receives the notice of cancellation. Any cancellation of Plan will not affect any services or discounts received by a canceling Member before the effective date of the cancellation.

Members who file chargebacks with their merchant provider will be reported to all major credit bureaus as a delinquent collection account. Please contact us before filing a dispute with your credit card company or bank. We will work to resolve any unauthorized transactions debited from your account.

If a resident of the state of Illinois remains dissatisfied after completing the organization's complaint process, the plan member may contact the Department of the Insurance at:

Illinois Department of Insurance
320 W. Washington
Springfield, IL 62767
(217)524-4051

TERMS AND CONDITIONS

THIS PROGRAM IS NOT INSURANCE. The cardholder is responsible to pay 100% of the purchase price for all drugs. The purchase price includes the discounted cost of the drug plus all dispensing fees. The cardholder pays the lower of the discounted drug cost plus dispensing fees, or the participating pharmacy’s cash price to customers. The purchase price may vary by drug and by pharmacy. Discounted drugs must be purchased only at participating pharmacies. All discounted drugs may not be available at all participating pharmacies.

The Liberty Rx Prescription Plan is administered by EnvisionRxOptions (the “Program Administrator”). The Program Administrator has negotiated discounts and dispensing fees with a network of participating pharmacies, and has contracted with the sponsor of the Program named on your card (the “Program Sponsor”) to provide access to discounted drugs by cardholders through the participating pharmacies. No portion of the drug cost or dispensing fees for drugs purchased by cardholders under the Program is paid by the Program Sponsor or Program Administrator.

Cardholders are advised to check the company website periodically for program updates. Contact the toll-free number on your card for more information or inquiries.

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Accepted Cards: Amex, Visa, Mastercard, Discover

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Total:

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