Save & Return

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Welcome to Mandell's Clinical Pharmacy's secure registration form. Please enter your information below to complete your registration.
Pricing will be provided once the order has been processed.
Please Note: Price Quotes are typically sent within 1 - 3 business days.
The price quote provided will be the out of pocket price. If your order contains ancillary products (antibiotic, or other medications that are not fertility specific), they should be covered by insurance for your regular co-pays. In this price quote you will receive an estimate on the ancillary products as they are typically inexpensive.
If submitting for next-day delivery, this form must be submitted no later than 4:30PM EST/2:00PM PST the day before expected shipment. 
Have you been approved for Compassionate Care? * 🛈
If you know that you have coverage for infertility medications, please be advised that the injectables will need a prior authorization. Until the prior authorization is done, we will not be able to fully transmit a claim. When you are ready to cycle, we are happy to fill your order and assist with the prior authorization process. Meanwhile, we can provide you with out of pocket pricing if you wish.

Once you are finished completing this form, we recommend that you visit to review discount programs.  We recommend you apply for Compassionate Care to determine if you qualify for additional savings based on your income.  
Please retrieve your prescription card - you may have one insurance card or two. If you have one, there will likely be prescription related information on it.  If you have two cards, please verify that you have your prescription card - a good way to tell is there will be "RX" information on the card.
Once you confirm you have the correct card, please enter it below by either taking a picture of the front and back, or manually entering the information. Please note that any incomplete or inaccurate informtion could delay or prevent successful investigation of your insurance. 

If you did not provide pictures of your prescription card above, please complete the area below.