OnlyHealthInsurance’s Prescription Drug Form For assistance in evaluating Medicare Prescription Drug plan options, please complete this form thoroughly and submit. Thank you. Full Name Email Zip Code Do you have a pharmacy preference?NoYesPharmacy Name: May we communicate by email?NoYesEmail Prescriptions Please list only the prescription drugs you are currently taking and not medications you are discontinuing or may have used in the past but no longer use. If there is a medication you expect to take but has not yet been prescribed, please include the name so we can check the formulary drug lists of high ranking plans. Generally, over-the-counter medications are not covered under Part D plans. Medication Name(s)Drug Type (Tab, Cap, Lotion, Drops, Ointment, Patch)Dosage (mg, mcg, ml, etc)Quantity (Doses per month, i.e.: 30, 60, 90)For ‘as needed’ medicine, indicate how many prescriptions filled per year, (i.e., 1 x, 3 x, 4 x, etc.)Generic OK? (yes/no) Once received, we will begin researching prescription drug plans for you. We will then forward you our report and recommendation, schedule an appointment to answer your questions, and assist with enrollment as necessary. Please note that your information will be used solely for the purpose of researching prescription drug plans. Your information will not be shared with insurance companies or individuals outside our office.CommentsThis field is for validation purposes and should be left unchanged.
