MEDICARE DRUG OR ADVANTAGE PLAN COUNSELING TOOL

MEDICARE DRUG OR ADVANTAGE PLAN COUNSELING TOOL

2024
Get improved help with your Medicare choices by creating a MyMedicare.gov account:

Medicare is improving and modernizing the new Medicare Plan Finder, the tool the SHIP Benefits Assistance Program at the Area Agency on Aging uses to compare Medicare Prescription Drug Plans and Medicare Advantage Plans. To provide a personalized plan comparison, you will need to create a MyMedicare.gov account. The goal is to provide a seamless and transparent experience to help you get the information you need to make good health care choices.
Already have a MyMedicare.gov account?

This will be used to complete your 2024 Drug Plan or Medicare Advantage Plan comparison
Username
Password
Don’t have a MyMedicare.gov account yet?
Create your account at MyMedicare.gov and click “Log in or create an account” OR a SHIP counselor can help you create an account.
For a personalized plan comparison, you will need a MyMedicare.gov account.
Authorization: I authorize the SHIP Benefits Assistance Program to use my Medicare.gov account to complete my plan comparison and or create an account if I don’t have one.
Signature
Date

MonthDayYear
Date
Your name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your email address
example@example.com
Phone Number
Please enter a valid phone number.
Gender

MaleFemale
Your SHIP counselor name
Please provide your Medicare number exactly as it is shown on your red, white & blue card that you received from Social Security:
Medicare Number
Start Date for:
Part A

MonthDayYear
Date
Part B

MonthDayYear
Date
Married?

YesNo
Total Gross Household Monthly income
Do you have savings or investments of more than $16,660 as a single person or $33,240 as a couple?

YesNo
Do you want a:

Drug PlanMedicare Advantage Plan
Preferred pharmacy #1?
Preferred pharmacy #2?
Instructions: Give the complete name of each medication, including any suffixes, such as Hcl, ER, HFA, etc. Indicate whether drug is a tablet, capsule, ointment, etc.

Name of Medication

	Example: Metformin Hcl	Tablet, Capsule, etc.	Strength(10 mg)	Daily Dosage
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Information will be limited to only the top 3 Drug Plans or Health Plans that meet your specific needs.Results will be completed and given to you within 10 business days. Please indicate how you want to

EmailRegular mail
Send to: Area Agency on Aging, Region One, 1366 E. Thomas Road, Suite 108, Phoenix AZ 85014

The SHIP Benefits Assistance Program, does not recommend or endorse any drug plan or Medicare Advantage Plan and is not responsible for the service provided by these companies. Your information is confidential and will be securely stored in your SHIP file

Revised: 09/15/2023
Should be Empty:

MEDICARE DRUG OR ADVANTAGE PLAN COUNSELING TOOL

Already have a MyMedicare.gov account?

Start Date for: