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Receive Free Pharmacy Services

Find out if you Qualify for Free Home Delivery and Free Customized Medicine Packs by Completing the Form Below.
How to get Free Pharmacy Services:

Do you or someone you care for need an easier way to get medicines without extra costs? Imagine getting your medications packaged in free, easy-to-use strips (called Good DAYPACKS) and delivered right to your doorstep at no extra cost. Keep reading to find out if you're eligible and learn how to gain access to these complimentary services.
Patient (Client) Name*

First NameLast Name
Patient (Client) Date of Birth*

MonthDayYear
Date
To qualify for free delivery and complimentary Good DAYPACKS (custom-packed medications organized by dosing time), you must fulfill the criteria of at least one of the following paths:

Path One - You have Medicare Insurance and you are enrolled in a Home and Community-Based Services (HCBS), a waiver program, or a Program of All-Inclusive Care for the Elderly (PACE).

OR

Path Two: You have Medicare Insurance and you need help with at least two activities of daily living (ADLs) or instrumental activities of daily living (IADLs) and meet at least one of the 'Additional Qualifiers Criteria' selections from the categories specified below.

Path Two criteria will populate after selecting 'No, not enrolled in any of these programs' in the following question.
Do you or the person you are applying for have Medicare Insurance?*

YesNo
Are you or the person you are applying for currently enrolled in any of the following programs?*

Yes, enrolled in a Home and Community-Based Services (HCBS) program.Yes, enrolled in a waiver program.Yes, enrolled in a Program of All-Inclusive Care for the Elderly (PACE) program.No, not enrolled in any of these programs (or unsure if enrolled in a program).
Next Steps for Those Not Currently Enrolled in HCBS, Waiver, or PACE Programs

If you selected 'No, not enrolled in any of these programs' in the question above, you still may be eligible for our specialized pharmacy services based on other criteria. Please review the information below to determine if you meet the necessary qualifications.

Path Two Eligibility Criteria:

To qualify, an individual must require assistance with at least two of the following activities of daily living (ADLs) or instrumental activities of daily living (IADLs), in addition to meeting at least one of the 'Additional Qualifiers' criteria from the categories listed below.

By thoroughly completing the next sections, you'll help us determine eligibility and the best way to support you or your loved one with our specialized pharmacy services.
Please specify any Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs) that the patient needs or receives help with (You must select at least two applicable options from the following list.).*

Managing Medication: The ability to obtain medications andtake them as directed.Transportation: The ability to attend events and/or manage transportation either via self-driving or by organizing other means of transportation.Managing Finances: The ability to pay bills and/or manage financial assets.Ambulating: The ability to move from one position to another and walk independently.Housecleaning/Home Maintenance: The ability to clean one’s kitchen after eating, maintain reasonably clean and tidy living areas, and keep up with home maintenance.Feeding: The ability to adequately feed oneself.Dressing: The ability to select appropriate clothes and put clothes on.Shopping/Meal Preparation: The ability to accomplish everything required to prepare meals; the ability to independently shop for clothing and other items required for daily life.Managing Communication with Others: The ability to manageand utilize the telephone or mail services.Personal Hygiene: The ability to bathe and groom oneself, including dental hygiene, nail, and hair care.Continence: The ability to consistently control one’s bladder and bowel function.Toileting: The ability to get to and from the toilet, use it appropriately, and clean oneself.NONE OF THE ABOVE
Please specify any Instrumental Activities of Daily Living (IADLs) that the patient needs or receives help with.*

Transportation: The ability to attend events and/or manage transportation either via self-driving or by organizing other means of transportation.Managing Finances: The ability to pay bills and/or manage financial assets.Shopping/Meal Preparation: The ability to accomplish everything required to prepare meals; the ability to independently shop for clothing and other items required for daily life.Housecleaning/Home Maintenance: The ability to clean one’s kitchen after eating, maintain reasonably clean and tidy living areas, and keep up with home maintenance.Managing Communication with Others: The ability to manage and utilize the telephone or mail services.Managing Medication: The ability to obtain medications and take them as directed.NONE OF THE ABOVE
Additional Qualifiers Criteria: To qualify, you need to meet at least ONE of the criteria listed below (select from the six provided options):*

Taking multiple prescription medications (minimum of 6)Have multiple chronic conditions (minimum of 3) - see list of chronic conditions belowRecent Skilled Nursing Facility (SNF) stay, hospitalization, ER visit, or receiving home health services/support from agencyNeeds assistance coordinating care, including pharmacy careLimited mobility that makes leaving the home difficult without assistanceNONE OF THE ABOVE
Chronic Conditions - Developed by Centers for Medicare and Medicaid Services (CMS)
- Acute Myocardial Infarction
- Alzheimer's Disease
- Anemia
- Asthma
- Atrial Fibrillation and Flutter
- Benign Prostatic Hyperplasia
- Cancer, Breast
- Cancer, Colorectal
- Cancer, Endometrial
- Cancer, Lung
- Cancer, Prostate
- Cancer, Urologic (Kidney, Renal Pelvis, and Ureter) NEW!
- Cataract
- Chronic Kidney Disease
- Chronic Obstructive Pulmonary Disease
- Depression, Bipolar, or Other Depressive Mood Disorders
- Diabetes
- Glaucoma
- Heart Failure and Non-Ischemic Heart Disease
- Hip/Pelvic Fracture
- Hyperlipidemia
- Hypertension
- Hypothyroidism*
- Ischemic Heart Disease
- Non-Alzheimer's Dementia†
- Osteoporosis With or Without Pathological Fracture
- Parkinson's Disease and Secondary Parkinsonism NEW!
- Pneumonia, All-cause NEW!
- Rheumatoid Arthritis/Osteoarthritis
- Stroke/Transient Ischemic Attack
For More Information or Additional Clarification - Please visit CMS HERE
Please List the Chronic Conditions/Diagnoses:*
Congratulations! You, or the person you are applying for, qualify for specialized pharmacy services.

You or your loved one qualifies for our specialized pharmacy services, including free medication strip packaging (Good DAYPACKS) and free delivery, designed to make medication management easier and more convenient.

To proceed and take advantage of our tailored services, please complete the following fields of information below.

After filling in the fields below, click the Submit button to finalize your qualification process.
Based on the current selections made, you, or the person you are applying for, do not currently qualify for specialized pharmacy services.

While you or your loved one may not yet qualify to receive FREE monthly specialized pharmacy services, including free medication strip packaging (Good DAYPACKS) and free delivery, we encourage you to review the eligibility criteria again or reach out to us for further assistance. Our services are designed to make medication management easier and more convenient, and we would love to have the opportunity to serve you in the future.

For any questions or to learn more about how you might meet the qualifications in the future, please do not hesitate to contact us.

We appreciate your interest in our services and hope to be able to assist you soon.
Please select the category that best represents you.*

I am the PatientI am a home health nurse or agent of the home health agencyI am a family/friend caregiverI am a host home provider
Your Name*

First NameLast Name
Home Health Agency Name:*
Relationship to Patient*
Phone Number*
Please enter a valid phone number.
Home Health Agency Phone Number*
Please enter a valid phone number.
Family Member or Caregiver's Phone Number*
Please enter a valid phone number.
Host Home Provider Phone Number*
Please enter a valid phone number.
Email
example@example.com
Today's Date*

MonthDayYear
Date
Your Signature*

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