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Pharmacy Benefits Plan Enrollment

Enroll in prescription Drug Benefits under

Agent Bruce Lanzerotti

blanzerotti@myhst.com

Cell 6308655134

Office 6303449555

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First Name

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Middle Name

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Last Name

25 characters max

Social Security Number (Optional)

Not required. If left blank, we will populate with an alternative ID for our records.

Date of Birth

Gender

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E-mail Address

Phone

Effective Date

© PRAM

Add Bank Account

Help on Finding Routing/Account Numbers on a Check

Confirmation

Confirmation

Are you sure you want to opt out of all electronic mailings and communications?

By doing so, you agree to NOT RECEIVE any of the following:

Member Welcome Packet by email
Electronic ID cards
Electronic Payment confirmations

System Message

ATTENTION! Is this your first enrollment? If YES, please read this.

Name

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Phone

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Add Credit Card

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Add Bank Account

Help on Finding Routing/Account Numbers on a Check

#CARDTYPEANDNUMBER#

#PAYMENTMETHODACTIVE#

Make Default

#ACCOUNTNAMEVALUE#

#PAYMENTMETHODACTIVE#

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PRAM Agreement

, By attesting to this agreement, you acknowledge an update to your PRAM appointment to include the sales of uninsured products.

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Confirmation

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INCOMING CALL

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