Generic Drug Program Application

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Identification

Please note: Individuals that have private drug insurance are not eligible for the Generic Drug Program.

I certify that I do not have private drug insurance.

No Private Drug Insurance Acceptance *

First Name *

Middle Initial

Last Name *

Address 1 *

Address 2

City, Town or Community *

Province *

Postal Code *

For example: C1B 0X1 or 12345

Country *

Telephone Number *

For example 902-555-5555

Email Address

Personal Health Number (PHN) *

Please enter the 8-digits from your PEI health card.

Date of Birth *

You must be under the age of 65 to apply.

Year

Month

Day

Is your spouse included in your application? *

If your spouse has private insurance, he/she is not eligible for coverage provided by the Generic Drug Program.