2023 Medicare Prescription Drug Plan Comparison Request

Montgomery County SHIP can help you select the Medicare Prescription Drug plan that best meets your needs for 2023. 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 NameLast 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

Street Address*

Apartment Number

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?*

YesNo

Alternate Telephone Number

Include Area Code, NO hyphens or spaces

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

YesNo

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 it against upcoming changes in 2023 and other plans.

Are you new to Medicare Part D?*

YESNO

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 have employer/union or retiree health coverage in 2023*

YESNO

I have Extra Help (LIS).*

YESNO

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

100% subsidy (you pay $3.95/$9.85)Partial subsidyI 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.)*

YESNO

I have Medicaid.*

YesNo

Your Prescription Drugs

List all the prescription drugs you take regularly.
Do not include over-the-counter medications.
List the full drug name as it appears on the package; be sure to include if it is Extended Release (ER).
If you do not currently take prescription drugs, leave the Drug Name field blank. We will send you information on the lowest costs plans available.

Are you currently taking prescription drugs?*

YesNo

Prescription #1 Full Name of Drug

Leave blank if you do not currently take prescription drugs

Drug #1: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #1 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #1 Type *

Drug #1 Dosage/Strength*

Drug #1 Frequency of Use*

Drug #1 Specific Type*

Drug #1 Strength*

Drug #1 Package Size and Type*

Drug #1 Number of Items in each Purchase *

Drug #1 Frequency of Purchase*

Prescription #2: Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #2: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #2 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #2 Type *

Drug #2 Dosage/Strength*

Drug #2 Frequency of Use*

Drug #2 Specific Type*

Drug #2 Strength*

Drug #2 Package Size and Type*

Drug #2 Number of Items in each Purchase *

Drug #2 Frequency of Purchase*

Prescription #3: Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #3: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #3 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #3 Type *

Drug #3 Dosage/Strength*

Drug #3 Frequency of Use*

Drug #3 Specific Type*

Drug #3 Strength*

Drug #3 Package Size and Type*

Drug #3 Number of Items in each Purchase *

Drug #3 Frequency of Purchase*

Prescription #4 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #4: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #4 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #4 Type *

Drug #4 Dosage/Strength*

Drug #4 Frequency of Use*

Drug #4 Specific Type*

Drug #4 Strength*

Drug #4 Package Size and Type*

Drug #4 Number of Items in each Purchase *

Drug #4 Frequency of Purchase*

Prescription #5 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #5: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #5 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #5 Type *

Drug #5 Dosage/Strength*

Drug #5 Frequency of Use*

Drug #5 Specific Type*

Drug #5 Strength*

Drug #5 Package Size and Type*

Drug #5 Number of Items in each Purchase *

Drug #5 Frequency of Purchase*

Prescription #6 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #6: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #6 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #6 Type *

Drug #6 Dosage/Strength*

Drug #6 Frequency of Use*

Drug #6 Specific Type*

Drug #6 Strength*

Drug #6 Package Size and Type*

Drug #6 Number of Items in each Purchase *

Drug #6 Frequency of Purchase*

Prescription #7 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #7: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #7 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #7 Type *

Drug #7 Dosage/Strength*

Drug #7 Frequency of Use*

Drug #7 Specific Type*

Drug #7 Strength*

Drug #7 Package Size and Type*

Drug #7 Number of Items in each Purchase *

Drug #7 Frequency of Purchase*

Prescription #8 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #8: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #8 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #8 Type *

Drug #8 Dosage/Strength*

Drug #8 Frequency of Use*

Drug #8 Specific Type*

Drug #8 Strength*

Drug #8 Package Size and Type*

Drug #8 Number of Items in each Purchase *

Drug #8 Frequency of Purchase*

Prescription #9 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #9: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #9 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #9 Type *

Drug #9 Dosage/Strength*

Drug #9 Frequency of Use*

Drug #9 Specific Type*

Drug #9 Strength*

Drug #9 Package Size and Type*

Drug #9 Number of Items in each Purchase *

Drug #9 Frequency of Purchase*

Prescription #10 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #10: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #10 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #10 Type *

Drug #10 Dosage/Strength*

Drug #10 Frequency of Use*

Drug #10 Specific Type*

Drug #10 Strength*

Drug #10 Package Size and Type*

Drug #10 Number of Items in each Purchase *

Drug #10 Frequency of Purchase*

Prescription #11 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #11: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #11 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #11 Type *

Drug #11 Dosage/Strength*

Drug #11 Frequency of Use*

Drug #11 Specific Type*

Drug #11 Strength*

Drug #11 Package Size and Type*

Drug #11 Number of Items in each Purchase *

Drug #11 Frequency of Purchase*

Prescription #12 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #12: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #12 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #12 Type *

Drug #12 Dosage/Strength*

Drug #12 Frequency of Use*

Drug #12 Specific Type*

Drug #12 Strength*

Drug #12 Package Size and Type*

Drug #12 Number of Items in each Purchase *

Drug #12 Frequency of Purchase*

Prescription #13 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #13: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #13 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #13 Type *

Drug #13 Dosage/Strength*

Drug #13 Frequency of Use*

Drug #13 Specific Type*

Drug #13 Strength*

Drug #13 Package Size and Type*

Drug #13 Number of Items in each Purchase *

Drug #13 Frequency of Purchase*

Prescription #14 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #14: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #14 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #14 Type *

Drug #14 Dosage/Strength*

Drug #14 Frequency of Use*

Drug #14 Specific Type*

Drug #14 Strength*

Drug #14 Package Size and Type*

Drug #14 Number of Items in each Purchase *

Drug #14 Frequency of Purchase*

Prescription #15 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #15: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #15 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #15 Type *

Drug #15 Dosage/Strength*

Drug #15 Frequency of Use*

Drug #15 Specific Type*

Drug #15 Strength*

Drug #15 Package Size and Type*

Drug #15 Number of Items in each Purchase *

Drug #15 Frequency of Purchase*

Prescription #16 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #16: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #16 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #16 Type *

Drug #16 Dosage/Strength*

Drug #16 Frequency of Use*

Drug #16 Specific Type*

Drug #16 Strength*

Drug #16 Package Size and Type*

Drug #16 Number of Items in each Purchase *

Drug #16 Frequency of Purchase*

Prescription #17 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #17: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #17 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #17 Type *

Drug #17 Dosage/Strength*

Drug #17 Frequency of Use*

Drug #17 Specific Type*

Drug #17 Strength*

Drug #17 Package Size and Type*

Drug #17 Number of Items in each Purchase *

Drug #17 Frequency of Purchase*

Prescription #18 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #18: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #18 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #18 Type *

Drug #18 Dosage/Strength*

Drug #18 Frequency of Use*

Drug #18 Specific Type*

Drug #18 Strength*

Drug #18 Package Size and Type*

Drug #18 Number of Items in each Purchase *

Drug #18 Frequency of Purchase*

Prescription #19 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #19: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #19 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #19 Type *

Drug #19 Dosage/Strength*

Drug #19 Frequency of Use*

Drug #19 Specific Type*

Drug #19 Strength*

Drug #19 Package Size and Type*

Drug #19 Number of Items in each Purchase *

Drug #19 Frequency of Purchase*

Prescription #20 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #20: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #20 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #20 Type *

Drug #20 Dosage/Strength*

Drug #20 Frequency of Use*

Drug #20 Specific Type*

Drug #20 Strength*

Drug #20 Package Size and Type*

Drug #20 Number of Items in each Purchase *

Drug #20 Frequency of Purchase*

Prescription #21 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #21: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #21 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #21 Type *

Drug #21 Dosage/Strength*

Drug #21 Frequency of Use*

Drug #21 Specific Type*

Drug #21 Strength*

Drug #21 Package Size and Type*

Drug #21 Number of Items in each Purchase *

Drug #21 Frequency of Purchase*

Prescription #22 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #22: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #22 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #22 Type *

Drug #22 Dosage/Strength*

Drug #22 Frequency of Use*

Drug #22 Specific Type*

Drug #22 Strength*

Drug #22 Package Size and Type*

Drug #22 Number of Items in each Purchase *

Drug #22 Frequency of Purchase*

Prescription #23 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #23: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #23 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #23 Type *

Drug #23 Dosage/Strength*

Drug #23 Frequency of Use*

Drug #23 Specific Type*

Drug #23 Strength*

Drug #23 Package Size and Type*

Drug #23 Number of Items in each Purchase *

Drug #23 Frequency of Purchase*

Prescription #24 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #24: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #24 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #24 Type *

Drug #24 Dosage/Strength*

Drug #24 Frequency of Use*

Drug #24 Specific Type*

Drug #24 Strength*

Drug #24 Package Size and Type*

Drug #24 Number of Items in each Purchase *

Drug #24 Frequency of Purchase*

Prescription #25 Full Name of Drug

Leave blank if you do not currently take additional prescription drugs

Drug #25: Specify Brand Name or Generic*

Brand NameGenericI don't know

Drug #25 Drug Form*

Pill (tablet or capsule)Other (drops, cream, ointment, gel, inhaler, injectable, other)

Drug #25 Type *

Drug #25 Dosage/Strength*

Drug #25 Frequency of Use*

Drug #25 Specific Type*

Drug #25 Strength*

Drug #25 Package Size and Type*

Drug #25 Number of Items in each Purchase *

Drug #25 Frequency of Purchase*

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