This registration form will be utilized by a Third-Party Administrator, Plan Sponsor or designee to receive
and/or share pharmacy, plan and/or medical data required for submission by the Center for Medicaid and Medicare
Services (CMS). Annual data reporting submissions after December 31, 2021 are due by June 1st each calendar year
for the previous year’s pharmacy, plan and medical data.
Email:
Password:
* Required Fields
Email:
*Password
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Passwords do not match
Password Requirements:
2 Numbers, 2 Special Characters, 2 Uppercase, 2 Lowercase, at least 10 length
*ReType Password
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*TPA/Plan Sponsor/Other
*First Name
Middle Name
*Last Name
*Landline Phone
*Cell phone
*Relationship To Client
Backup Contact Email
Backup Contact First Name
Backup Contact Last Name
Backup Contact LandLine
Backup Contact CellPhone
Note: Plan is responsible for providing additional data if Sav-Rx is to support
previous PBM relationships the Plan has during a full plan year. Additional charges may
apply for combing previous PBM data.
Plan Sponsor Info
*Submission Option
*Billing Selection
*Plan Sponsor Name
*Plan Sponsor EIN
*Plan Sponsor State
*Sav-Rx Group Number
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