NALOXONE ORDER PAGE - Premier Drugstore

If you live in the State of Georgia, you can order your Naloxone Nasal Spray online today by using the order form below. If there is a copay, Premier Drugstore will contact you with the amount and a payment option. There is no cost to try it and see what your copay would be. The shipping address must be in Georgia. Shipping cost will be added to each order based on amount ordered.

Patient Information

Prefix

First Name *

Middle Name

Last Name *

Gender *

Date of Birth *DOB of Person Ordering

Last 4 of SSN0 / 4

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Do you have additional family members to add? *

Additional Insured Name *Additional Insured Name

Date of Birth *

Last 4 of SSN0 / 4

Do you have additional family members to add? *Do you have additional family members to add?

Additional Insured Name *Additional Insured Name

Date of Birth *

Last 4 of SSN0 / 4

Do you have additional family members to add? *Do you have additional family members to add?

Additional Insured NameAdditional Insured Name

Date of Birth *

Last 4 of SSN0 / 4

Do you have additional family members to add? *Do you have additional family members to add?

Additional Insured Name *Additional Insured Name

Date of Birth *

Last 4 of SSN0 / 4

Do you have additional family members to add? *Do you have additional family members to add?

Additional Insured Name *Additional Insured Name

Date of Birth *

Last 4 of SSN0 / 4

Insurance Information

We must either receive a picture of your card or you must enter the RxBIN, RxPCN, RxGrp, and Member ID from your card into form fields.

Member ID

Rx BIN0 / 6

RxPCN

RxGroup0 / 25

Additional Info0 / 500

Upload Picture of Insurance Card

Please make sure the image is clear. Please include front and back of card. Can upload multiple images.

Signature *

My signature below indicates that I authorize Premier Drugstore to bill my insurance company for a Naloxone Nasal Spray