The Fine Print

Terms: This prescription drug discount program (“Rx-tra Savings Program”) is administered by Medical Security Card Company (MSC) of Tucson, Arizona. In administering Rx-tra Savings Program, MSC receives individually identifiable health information (including but not limited to the information provided on this enrollment form) from Albertsons, the pharmacies processing Rx-tra Savings Program transactions or directly from you. Your authorization is required as a condition of enrollment in the Rx-tra Savings Program as MSC must have this information to administer its point-of-sale discount prescription service. The individually identifiable health information provided to MSC and Albertsons is not transferred, sold or otherwise disclosed to third parties, except as necessary for the proper administration of Rx-tra Savings Program or as may be otherwise required by law, and is always protected as Confidential Private Information. If your medical information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by a person who receives your medical information and this re-disclosure may not be protected by the applicable privacy laws. For additional information, including the Albertsons privacy policy, please visit: www.albertsons.com.

Authorization: I understand that my signature on this enrollment form constitutes my written authorization for MSC to receive and use the individually identifiable health information described above for the proper administration of Rx-tra Savings Program in accordance with applicable law. This authorization shall remain in effect for the duration of my enrollment in the Rx-tra Savings Program. I have the right to revoke this authorization in writing at any time by contacting Medical Security Card Company at 4911 E. Broadway Blvd, Suite 200, Tucson, AZ 85711 except to the extent that my medical information has already been used or disclosed in reliance on this authorization. However, because this information is essential to the administration of this program, my revocation of this authorization shall result in cancellation of my enrollment in the Rx-tra Savings Program. If you are signing on behalf of dependent family members, your signature verifies that you are the parent/legal guardian or the authorized representative of the individuals identified above.

Additional Health Savings Information: Pursuant to your enrollment in the Rx-tra Savings Program, MSC and Albertsons may also provide you with special information to enhance your health, such as drug price comparisons, and/or special savings opportunities (additional health savings information) through programs administered by MSC and/or Albertsons. Your signature below constitutes your written authorization for MSC and Albertsons to provide you with Additional Health Savings Information as described above. You may opt out of receiving future transmissions of Additional Health Savings Information by contacting MSC’s customer service department at 1-866-223-9675.

DISCOUNT ONLY – NOT INSURANCE. Discounts are available exclusively through participating pharmacies. Persons receiving benefits from a publicly funded health care program, including Medicaid and Medicare, are ineligible. You may cancel your registration under the Rx-tra Savings Program at any time by contacting 1-866-223-9675. This program is administered by Medical Security Card Company (MSC) of Tucson, Arizona. By using your card, you acknowledge and agree that MSC may have access to and use your prescription drug data to administer the program. Your Plan Sponsor and MSC reserve the right to modify or discontinue this program at any time and are not responsible for the independent professional services of any participating pharmacy. You can view our complete Privacy Policy on our website at http://www.scriptsave.com/privacy.aspx.