Information Request

If you would like to learn more about WisconsinRx, please complete the brief questionnaire below. One of our staff will contact you.

Company Name:
Address:
Address Line 2:
City:	State:
ZIP:
Contact Name:
Title:
Telephone Number:	( ) - ext
Fax:	( ) -
E-mail Address:

Are you ?	self-funded fully insured
What insurance company, HMO, or network do you use?
Total employees:
Who is your current Pharmacy Benefit Manager (PBM) and Third Party Administrator (TPA)?
What is your plan renewal date?
Earliest anticipated date able to change PBMs:

If you prefer, you may print this form and mail it to :
WisconsinRx, P.O. Box 14732, Madison, WI 53708