Official Local 3 Union Member Opt-in Form

Introducing the PlaidRx Savings Program—your solution to reducing costs on high-cost brand-name and specialty medications! Designed with the Local 3 Health & Welfare Fund in mind, our program goes above and beyond by eliminating copayments for plan members, making it a $0 expense for you. What's more? Benefit from the added convenience of medication delivery straight to your door. But that's not all—unlock access to expert pharmacare for any questions, concerns and guidance. Say goodbye to high costs, unnecessary trips to the pharmacy and hello to savings with PlaidRx!

To see if you qualify, please fill out the form and schedule a 15 minute enrollment call with your dedicated Local 3 patient advocate.

For any questions, please contact:

Support@Plaid-Rx.com | 708-575-7787 or Organize@local3.org | 312-243-4300
Note: If you do not see your brand medication on the list please select 'Other'.
Select your requested medication(s):*
If Other was selected, please provide the medication(s) you are requesting:
Questions? Reach out to us at support@plaid-rx.com

You have selected a medication that requires additional approval.

Please fill out the following form to complete your request.
Congratulations! One or more of your medications qualify for 100% savings. Your full request will be processed and you will be notified by a member of our team shortly.

Fill out the form below to transfer your prescription and eliminate your co-pay.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Prescription Transfer Request:*
Primary Care Physician Name
Primary Care Physician Phone Number
Please enter a valid phone number.
Please provide a photo of your photo ID or insurance card, either by uploading it or by taking a picture.

One form of identification required.
Photo ID or Insurance Card:*

Cancelof
Photo of ID or Insurance Card:*
I do not have my ID or insurance card with me.*

I will upload my ID or insurance card at a later time
Best Date and Time to be Reached: *

MonthDayYear
Date
Hour MinutesAM/PM Option
Additional Notes:
Signature*

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Member Consent*
For any questions please contact us at: support@plaid-rx.com
Should be Empty:

You have selected a medication that requires additional approval.