Medicare Part D Prescription Drug Form 2020

2020 Prescription Drug Form

 

For assistance in evaluating Medicare Prescription Drug plan options for 2020, please thoroughly complete this form and return to us by mail, fax or scan/email. If by fax or email, also mail us a check for the $175 consulting fee payable to OnlyHealthInsurance. Once received, we will forward you the results of our research, schedule an appointment to answer your questions, and assist with enrollment as necessary.

Name:                                                                                                                          Zip Code:

Current Prescription Drug Plan Carrier & Full Plan Name:

Do you have a preferred pharmacy? If so, provide pharmacy name:

May we communicate by email? If so, provide e-mail address:

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.

 

 

Medications

 

Dosages (mg,mcg,ml)

Quantity

(How many 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.)

 

Brand Name Drug Required?

(Circle)

1. Yes / No
2. Yes / No
3. Yes / No
4. Yes / No
5. Yes / No
6. Yes / No
7. Yes / No
8. Yes / No
9. Yes / No
10. Yes / No

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.

OnlyHealthInsurance does not market or sell Part D plans.