VaultRx for Agents

1. Create Customer Account

This page is for represenatives to enroll members into the VaultRx Plan. Please input the customer's information below.

[Obtain information from member below and input into system]

Customer First Name

Customer Last Name

Customer Address

Customer Address 2

Customer City

Customer State

Customer Zip

Customer Email

Customer Phone

Customer Birth Date

Year

Month

Day

Customer Gender

2. Customer Payment Info

[Read the following to the customer]

We have a number of payment options available. We accept Visa, MasterCard or check/from account. Which will you be using today?

[Obtain information and input into system].

Payment Type

Credit Card

Check

Customer Card Type

Customer Card Number

Customer Expiration Month

Customer Expiration Year

Customer Account Number

Customer Routing Number

[Read the following to the customer]

Is your contact information different from your billing information?

[If “No” simply continue. If “Yes”, check box and obtain information and input into system.].

Customer Contact Information is Different from Billing Information

Customer Contact Information is Different from Billing Information”

Customer First Name

Customer Last Name

Customer Address

Customer Address 2

Customer City

Customer Zip

Customer State

By continuing, you acknowledge that: you are 18 years of age or older; you agree to register for a membership into VaultRx; and acknowledge that you have read, understand and agree to the VaultRx Terms and Conditions and hereby authorize the plan administrator, NBFSA, for VaultRx to deduct $19.95 from your account on a monthly basis. You understand that this authority shall remain in force until you notify VaultRx or their plan administrator NBFSA of its cancellation; You have given accurate information provided during this enrollment process; and this is not insurance. If you are not satisfied within 30 days after the effective date, you can call 888-424-4186. The Program will then be canceled and any Charges /Fees paid, as shown above, will be refunded.

Summary

Benefits
VaultRx

Total $19.95

ValutRx Membership Disclaimers

VaultRx is a platform which supports group sponsored prescription drug benefit plans. Access to the benefit plans hosted on the VaultRx platform and any use of the VaultRx platform is restricted to designated groups and their eligible members. VaultRx is not intended for use related to programs that are made available to the general public.

Processing Enrollment

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Please try again. If the problem persists contact customer service at 888-424-4186

1. Create Customer Account

2. Customer Payment Info

Summary

Processing Enrollment

Enter Your Representative ID to Continue

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