Thank you for accessing the Synchrony Rx@HOME 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 Rx@HOME 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