2023 Prescription Plan Information

My 2023 Prescription Medication List for Review
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Do you use any Tobacco products (or have used them in the last 12 months)?

YesNo
Preferred Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What COUNTY do you live in?
County
Are you a Veteran?
If you are a Veteran, do you use the VA for your prescriptions?
My Pharmacy Preferences (Please put in multiple choices unless you will ONLY go to one pharmacy even if it costs more).*
Mail Order and SeniorCare Rx Options*
Please enter ALL your prescriptions here. Use your bottle/container for reference. Include ALL details (XR, ER, etc.), Name, Type (tablet, capsule, ointment, cream, gel, pens, etc.), Dosage (1 mg, 25/12.5, etc.), Quantity (1x day, 15 per month, 1 box of pens, 2 inhalers per year, etc.) If you are on INSULIN, please just tell the number of pens you need per month. Be as specific as possible - seemingly small differences can make a huge price difference.
Who is your current Primary Care Physican?
Where is your doctor affiliated? (Example: Aurora, Ascension, Froedert, etc.)
Please provide any additional details you think might be helpful here -- Details are helpful!
Signature

Clear
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
If you would like to join our new mailing address, please put your preferred email for the mailings here (you can opt out at any time). We will have short, informative mailings from time to time.
example@example.com
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My 2023 Prescription Medication List for Review