Rx Drug Analysis Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Zip Code *

County *

Preferred Pharmacy *

Drug List

Medication 1

Drug Name *

Dosage (i.e. 20mg) *

Times Per Day *

Medication 2

Drug Name (M2) *

Dosage (i.e. 20mg) (M2) *

Times Per Day (M2) *

Medication 3

Drug Name (M3) *

Dosage (i.e. 20mg) (M3) *

Times Per Day (M3) *

Medication 4

Drug Name (M4) *

Dosage (i.e. 20mg) (M4) *

Times Per Day (M4) *

Medication 5

Drug Name (M5) *

Dosage (i.e. 20mg) (M5) *

Times Per Day (M5) *

Medication 6

Drug Name (M6) *

Dosage (i.e. 20mg) (M6) *

Times Per Day (M6) *

Medication 7

Drug Name (M7) *

Dosage (i.e. 20mg) (M7) *

Times Per Day (M7) *

Medication 8

Drug Name (M8) *

Dosage (i.e. 20mg) (M8) *

Times Per Day (M8) *

Medication 9

Drug Name (M9) *

Dosage (i.e. 20mg) (M9) *

Times Per Day (M9) *

Medication 10

Drug Name (M10) *

Dosage (i.e. 20mg) (M10) *

Times Per Day (M10) *

Provider List

Provider 1

Name *

First

Last

Specialty *

City *

Zip Code *

Provider 2

Name (P2) *

First

Last

Specialty (P2) *

City (P2) *

Zip Code (P2) *

Provider 3

Name (P3) *

First

Last

Specialty (P3) *

City (P3) *

Zip Code (P3) *

Provider 4

Name (P4) *

First

Last

Specialty (P4) *

City (P4) *

Zip Code (P4) *

Provider 5

Name (P5) *

First

Last

Specialty (P5) *

City (P5) *

Zip Code (P5) *

Comments or additional medications: *

By completing this form you agree that a licensed insurance agent may contact you by phone, mail or email to answer any questions you have regarding Medicare Advantage or Medicare Part D plans. This is a solicitation for insurance.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. This is a proprietary website and is not associated, endorsed or authorized by the Social Security Administration, the Department of Health and Human Services or the Center for Medicare and Medicaid Services. This site contains decision-support content and information about Medicare, services related to Medicare and services for people with Medicare. If you would like to find more information about the Medicare program please visit the Official U.S. Government Site for People with Medicare located at http://www.medicare.gov

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