• 2021 Medicare Drug Plan Worksheet

    Montgomery County SHIP can help you analyze your options for your 2021 Part D Prescription Drug Plan. For coverage to begin January 1, 2021, send your form before November 16, 2020!
  • INSTRUCTIONS

    Please list all your prescription drugs. Do not include over-the-counter medications 1) List the full drug name as it appears on the bottle, including if it is Extended Release (ER). ·2) Indicate if your drug is a brand-name medication or generic. (Ask your pharmacist if unsure.) We will assume you take the brand name unless you specify generic.· 3) For Quantity, if other than tablets or capsules, be specific about how many tubes/bottles/packs/ inhalers/etc. you need per month or per year. 
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