2025 AEP Prescription List

AEP Prescription List

Complete this form to have your prescription list sent to Tweedy Insurance Group in order to allow our agents to configure your plan options for the 2025 year and find which plan may work best for you. Please complete and submit one form each per individual.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email:
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like us to contact you for plan information and future communications?*

Phone and mailEmail
I agree to receive email communications from Tweedy Insurance Group to the above email address in place of receiving mail communication. I recognize that in order to revoke my consent, I will need to notify Tweedy Insurance Group of my request to stop receiving communications by email.
Agreement

Yes, I would like to receive email communications.
Medicare has created a new system that recommends that you create a MyMedicare.gov account in order to make plan comparisons. This system will allow you to have access to your Medicare claims, drug lists, and current plan information. Please select an option below:*

I believe I already have a MyMedicare.gov account.I need help setting up a MyMedicare.gov account and would like someone to call me to help me through the process.I will set up a MyMedicare.gov account before an agent will contact me.I prefer to not set up an account.
Current Plan Coverage
Ex. AARP Walgreens Plan
What are your top two preferred pharmacies?
Ex. Walgreens, Walmart
Do you (or would you be willing to) use mail order to receive medications?

YesNo
Do you currently take any prescription medications?*

YesNo
Please fill in ALL of the information for your current medications and click SAVE.*
Medicare Advantage Plans ONLY (not needed for PDP plans)
Doctors, Specialists, and/or facilities that you visit and want in the network for your new plan.
Are you new to Tweedy Insurance Group?*
How did you hear about Tweedy Insurance Group?

A friend recommended I talk to you.A company recommended I talk to you.I found you online.I received mail from you.Other
Which agent were you wanting to talk to?
After submitting this form, there is a link on the Thank You page that will allow you to complete the Scope of Appointment form. Please make sure to complete the Scope of Appointment form after submitting your list. The form allows us to discuss plan details with you about the specific plan types you choose. WE WILL NOT BE ABLE TO DISCUSS PLANS UNTIL WE HAVE THIS FORM.
Please check this box before submitting:*
We do not offer every plan available in your area. Currently we represent 12 organizations which offer 68 products in your area. Please contact Medicare.gov or 1-800-MEDICARE or your local State Health Insurance Program to get information on all of your options.
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