Applying through the mail Step 1: Tell us if you have Adobe Acrobat Reader: I do have Adobe Acrobat Reader. (Proceed to Step 2.) I do not have Adobe Acrobat Reader. (Click here.) Step 2: Print out the form and fill it in.           (Click here to download the form.) Be sure to review the Program information found on the application and fill out the form completely. An incomplete application will delay your enrollment. Step 3: Mail your completed form to:  Together Rx Access, LLC  PO Box 9426  Wilmington, DE 19809-9944 [ Back to Apply page ]       Printable application      Eligibility requirements Eligible individuals meet all four of the following requirements:  1. I am not eligible for Medicare. 2. I have no prescription drug      coverage of any kind. 3. My household income is equal      to or less than:     - $30,000 for a single person     - $40,000 for a family of two     - $50,000 for a family of three     - $60,000 for a family of four     - $70,000 for a family of five     Families of six or more and     residents of Alaska and Hawaii     should contact Together Rx     Access at 1-800-444-4106. 4. I am a legal resident of the      United States or Puerto Rico.    Not eligible? You may qualify for other prescription savings. Visit pparx.org for details. *Each cardholder’s savings depend on such factors as the particular drug purchased, amount purchased, and the pharmacy where purchased. Participating companies independently set the level of savings offered and the products included in the Program. Those decisions are subject to change.