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!
Name
*
First Name
Last Name
Would you like to receive your results sooner? Check Yes if you want your results sent by secure email. Check No if you want your results sent by regular mail. It may take up to 10 days to receive your results by mail.
*
YES (Email is required)
NO
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
*
Include Area Code, NO hyphens or spaces
*
Home
Mobile
Work
Other
Alternate Telephone Number
Include Area Code, NO hyphens or spaces
Home
Mobile
Work
Other
List 2 retail pharmacies you are willing to fill your prescriptions (e.g., CVS, Giant) Pharmacy 1
*
Pharmacy 2
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INSURANCE INFORMATION Please tell us your current Medicare Part D Prescription Drug Plan (if any).
Name of Drug Plan's Insurance Company
Exact Name of Your Current Plan
Monthly Premium (Current Plan)
If you are new to Medicare, what month/year will your Medicare Part D coverage start?
MM/YY
I will be enrolled in an employer health plan or FEHBP in 2021.
*
YES
NO
I have Extra Help (LIS)
*
YES
NO
If you answered YES to Extra Help, please specify:
100% subsidy (you pay $3.60/$8.95)
Partial subsidy
I am enrolled in the Maryland Senior Prescription Drug Plan Assistance Program (SPDAP). (I get help with my premium - up to $40/month in 2020.)
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YES
NO
I have Medicaid (Medical Assistance)
*
YES
NO
You may be eligible for Extra Help from Medicare depending on your income and assets. You may be eligible for Maryland's SPDAP if your income is below $38,280 (single) or $51,720 (couple), regardless of assets. Would you like SHIP to send you information about Extra Help or SPDAP?
Extra Help
SPDAP
Both
No, thank you!
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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.Â
Prescription #1: Full Name of Drug
Drug #1: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #1: Strength of Prescription
.005%, 5 mg, etc.
Drug #1: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #1 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #2: Full Name of Drug
Drug #2: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #2: Strength of Prescription
.005%, 5 mg, etc.
Drug #2: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #2 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #3: Full Name of Drug
Drug #3: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #3: Strength of Prescription
.005%, 5 mg, etc.
Drug #3: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #3 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #4: Full Name of Drug
Drug #4: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #4: Strength of Prescription
.005%, 5 mg, etc.
Drug #4: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #4 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #5: Full Name of Drug
Drug #5: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #5: Strength of Prescription
.005%, 5 mg, etc.
Drug #5: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #5 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #6: Full Name of Drug
Drug #6: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #6: Strength of Prescription
.005%, 5 mg, etc.
Drug #6: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #6 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #7: Full Name of Drug
Drug #7: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #7: Strength of Prescription
.005%, 5 mg, etc.
Drug #7: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #7 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #8: Full Name of Drug
Drug #8: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #8: Strength of Prescription
.005%, 5 mg, etc.
Drug #8: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #8 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #9: Full Name of Drug
Drug #9: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #9: Strength of Prescription
.005%, 5 mg, etc.
Drug #9: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #9 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #10: Full Name of Drug
Drug #10: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #10: Strength of Prescription
.005%, 5 mg, etc.
Drug #10: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #10 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #11: Full Name of Drug
Drug #11: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #11: Strength of Prescription
.005%, 5 mg, etc.
Drug #11: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #11 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #12: Full Name of Drug
Drug #12: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #12: Strength of Prescription
.005%, 5 mg, etc.
Drug #12: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #12 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #13: Full Name of Drug
Drug #13: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #13: Strength of Prescription
.005%, 5 mg, etc.
Drug #13: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #13 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #14: Full Name of Drug
Drug #14: Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #14: Strength of Prescription
.005%, 5 mg, etc.
Drug #14: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #14 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #15: Full Name of Drug
Drug #15 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #15: Strength of Prescription
.005%, 5 mg, etc.
Drug #15: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #15 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #16: Full Name of Drug
Drug #16 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #16: Strength of Prescription
.005%, 5 mg, etc.
Drug #16: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #16 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #17: Full Name of Drug
Drug #17 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #17: Strength of Prescription
.005%, 5 mg, etc.
Drug #17: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #17 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #18: Full Name of Drug
Drug #18 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #18: Strength of Prescription
.005%, 5 mg, etc.
Drug #18: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #18 Type: Capsule, Tablet, Ointment, Creams, Drops
Prescription #19: Full Name of Drug
Drug #19 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #19: Strength of Prescription
.005%, 5 mg, etc.
Drug #19: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #19 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #20: Full Name of Drug
Drug #20 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #20: Strength of Prescription
.005%, 5 mg, etc.
Drug #20: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #20 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #21: Full Name of Drug
Drug #21 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #21: Strength of Prescription
.005%, 5 mg, etc.
Drug #21: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #21 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #22: Full Name of Drug
Drug #22 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #22: Strength of Prescription
.005%, 5 mg, etc.
Drug #22: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #22 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #23: Full Name of Drug
Drug #23 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #23: Strength of Prescription
.005%, 5 mg, etc.
Drug #23: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #23 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #24: Full Name of Drug
Drug #24 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #24: Strength of Prescription
.005%, 5 mg, etc.
Drug #24: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #24 Shape: Capsule, Tablet, Ointment, Creams, Drops
Prescription #25: Full Name of Drug
Drug #25 Specify Brand Name or Generic
Brand Name
Generic
I don't know
Drug #25: Strength of Prescription
.005%, 5 mg, etc.
Drug #25: Quantity
Once per day, indicate 1X/day; 2 times = 2X/day, 1 cream every 3 mos, 1 bottle/month
Drug #25 Shape: Capsule, Tablet, Ointment, Creams, Drops
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