Prescription Drug Plan Analysis

SAFE • SECURE • EASY • CONFIDENTIAL
Section 1 - Applicant A Information
Format: MM/DD/YYYY
Height and Weight not required if age within 6 months before or after 65th Birthday.
Medicare Card

Please reference your Medicare Card to complete this section. Provide your Medicare Claim Number and Your Social Security Number.

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Section 1 - Applicant B Information
Format: MM/DD/YYYY
Height and Weight not required if age within 6 months before or after 65th Birthday.
Medicare Card

Please reference your Medicare Card to complete this section. Provide your Medicare Claim Number and Your Social Security Number.

1 (Show/Hide) 2 3
(Show/Hide)
 
Section 2 - Medication Information
 

Applicant A

Medication Name
(Please enter exact name from prescription label)
Have you taken this medication for more than 2 years?
Prescribed by Primary Physician?
Dosage
Frequency
Diagnosis / Condition
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No

Applicant B

Medication Name
(Please enter exact name from prescription label)
Have you taken this medication for more than 2 years?
Prescribed by Primary Physician?
Dosage
Frequency
Diagnosis / Condition
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Section 3 - Preferred Pharmacies
 

Applicant A

Pharmacies Applicant A
Pharmacy Name:
Address:
City:
State: Zip:
Pharmacy Name:
Address:
City:
State: Zip:

Applicant B

Pharmacies Applicant B
Pharmacy Name:
Address:
City:
State: Zip:
Pharmacy Name:
Address:
City:
State: Zip:

If you have any questions or need help completing this form, please contact us at 800-290-2246.

*Required Information