2022 Medicare Prescription Drug Plan Comparison Request

Montgomery County SHIP can help you select the Medicare Prescription Drug plan that best meets your needs for 2022. To compare your options, we need information about the pharmacies you are willing to use and the drugs you take routinely.

For Medicare Advantage options, call 1-800-Medicare.

Your Personal Information

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 10-15 business days to receive your results by mail.

Email My Results *

YES (Email is required) NO

Email

example@example.com

Address *

Street Address

Address Line 2

Street Address Line 2

City *

State *

Postal/Zip Code *

Telephone Number *

Include Area Code, NO hyphens or spaces

If needed, may we leave results in a voicemail message on this phone? *

Yes No

Alternate Telephone Number

Include Area Code, NO hyphens or spaces

If needed, may we leave results in a voicemail message on this phone?

Yes No

Your Pharmacies

List 2 retail pharmacies where you would be willing to fill your prescriptions (e.g., CVS, Giant, Walmart).

Pharmacy 1 *

Pharmacy 2

Your Current Plan Information

Please tell us your current Medicare Part D Prescription Drug Plan, if any, so we can compare against upcoming changes in 2022 and other plans.

Are you new to Medicare Part D? *

YES NO

If you are new to Medicare Part D, when will your coverage start? *

MM/YY

Your Current Plan

If your plan is not listed above, enter it here:

I will be enrolled in an employer/retiree-provided drug plan in 2022 (e.g. FEHBP, union, etc). *

YES NO

I have Extra Help (LIS). *

YES NO

If you answered YES to Extra Help, please specify: *

100% subsidy (you pay $3.95/$9.85) Partial subsidy I don't know

I am enrolled in the Maryland Senior Prescription Drug Plan Assistance Program (SPDAP). (I get help with my premium - up to $50/month in 2022.) *

YES NO

I have Medicaid. *

Yes No

Your Prescription Drugs

Please list all your prescription drugs. Do not include over-the-counter medications.

List the full drug name as it appears on the bottle . Be sure to include if it is Extended Release (ER).
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.·
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.

EXAMPLES

Drug Name	Brand or Generic	Dosage (RX Strength)	Quantity (1/day, 3/month, etc.)	Form (capsule, tablet, tube, drops)
Coumadin	Brand	5 mg	2/day	tablet
Latanoprost	Generic	.005%	One 2.5 ml bottle/3 months	drops

Quantity

For tablets/capsules: Once per day = 1X/day; 2 times = 2X/day
For drops/creams: 1 tube every 3 mos, 1 bottle/month

Are your currently taking prescription drugs? *

Yes No

Prescription #1: Full Name of Drug

Drug #1: Specify Brand Name or Generic

Brand Name Generic I don't know

Drug #1: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: 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: Dosage (Rx strength)

.005%, 75 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 Form: Capsule, Tablet, Ointment, Creams, Drops

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