Getting Started with PriceMDs SourceDirectRX

Thank you for your interest in the PriceMDs SourceDirectRX program. Please provide us with your information below and a PriceMDs Nurse Navigator will be in touch with you soon.

First Name

Last Name

Member ID

Date of Birth

Phone Number

E.g. +1 300 400 5000

Email Address

Name of the employer who you have health insurance with

What is your relationship to insured?

What is your preferred method of communication?

Preferred Days and Times

Is there a preferred time to be reached? (Hour)

Select a time.

Preferred Time (Minute)

Preferred Time (AM PM)

Time Zone

Medication Name

Enter your medication name.

Medication Strength

(E.g. 40mg, 3ml etc.)

Frequency of Use

(E.g. Twice a day, once a week etc.)

Is this a new medication?

NoYes

*PriceMDs cannot provide the first dose of any new medication.

Getting Started with PriceMDs SourceDirectRX

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