VaultRx - Consumer

1. Create Your Account

First Name

Last Name

Address

Address 2

City

State

Zip

Phone

Birth Date

Year

Month

Day

2. Payment

Payment Type

Credit Card

Check

Card Type

Card Number

Expiration Month

Expiration Year

Account Number

Routing Number

My Contact Information is Different from my Billing Information

First Name

Last Name

Address

Address 2

City

Zip

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.

Electronic Signature

Summary

VaultRx Prescription Plan

Total $19.95

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.

The Next Innovation In Prescription Drug Savings

1. Create Your Account

2. Payment

Summary

Processing Enrollment