Synchrony Pharmacy Enrollment Form

Synchrony Pharmacy Enrollment Form
Thank you for accessing the Synchrony Pharmacy Enrollment Form. All employees enrolled in the Trilogy Health medical plan should complete the following information. This form is designed to collect the necessary data in order for Synchrony Pharmacy to efficiently and effectively service your maintenance and specialty medication needs.

Please note that you will be required to enter the following information: Date of Birth, Last 4 of SSN, Employee ID, HSA/FSA number, Express Scripts ID Number, Primary Care Physician, List of Current Medications and Doses, Medication Allergies, Health Conditions, Information on Any Dependents on the plan

Date of Birth: (MM/DD/YYYY) *
Last 4 Digits of SSN: *
Employee ID
Employee ID: Numeric portion of your Trilogy University ID. Your Employee ID can be found in MyADP by navigating to the “Your Profile” tile on the home screen; your Employee ID will appear prominently on the page upon clicking on the tile.

If you still have issues with obtaining your Employee ID, contact your local HR representative
Invalid Information - Please Check Your Submissions
Birth Date
Last 4 SSN
First Name
Last Name
Home Address
Home Address Line 2
City
State
ZIP/Postal
Cell Phone
Please enter a valid phone number.
Email
Is the information listed above correct for the primary holder? *

Yes No
Correct Primary Holder Information *
Communication Preference *

Text Message Email Automated Call
FSA / HSA Card Information:
By Signing Below You Are Confirming and Accepting Payroll Deduction As A Form of Payment: *

Employee payroll must be sufficient to cover medication cost share in order to continue using payroll deduction to pay for prescriptions Clear
Preferred Form of Payment: *

FSA HSA Payroll Deduction
Primary Care Physician: *
Express Scripts Prescription ID Card Member Number:
Please enter any medication allergies. If no allergies, leave field blank:
Please enter any health conditions. If no health conditions, leave field blank:
Please enter any medications you are currently taking. If no active medications, leave field blank:
Are there dependents listed on your account? *

Yes No I Don't Know
Dependent Information (If Email, Phone, Mailing Address is Same as Primary, Enter Same) *
Please enter any medication allergies of above listed dependents. If no allergies, leave field blank:
Include Name(s) of Dependent
Please enter any health conditions of above listed dependents. If no health conditions, leave field blank:
Include Name(s) of Dependent
Please enter any medications the above listed dependents are currently taking. If no active medications, leave field blank:
Include Name(s) of Dependent
Should be Empty: