2026 AEP Prescription Worksheet

Prescription Worksheet

Submit this form to MSS and a team member will review your medications.
Name

First NameLast Name
Address

Street Address

City

StateCounty

Zip Code
Best Contact Number
Permission to Email
Email Address
example@example.com
Current Insurance Plan
Pharmacy
Are you willing to change your pharmacy?
Do you get help with your costs from one of these programs?
Appointment Options
Upload your saved Rx List or Complete Form Below

Please upload a clear, legible photo.
Cancelof

Example of Completed Rx List:

Medication Name	Dosage (mg)	Frequency (x taken per day)	Tablet, Capsule, Ointment, Fluid (Solution)
Lisinopril	20mg	1	Tablet
Metoprolol Succinate ER	25mg	1	Tablet

These drugs are not generally covered by Medicare Part D:
Vitamin D (50,000), Sildenafil (generic Viagra), Vitamin B-12, Folic Acid (1mg)

Please enter the information directly from the label on your Prescription Medication. Do not include any over-the-counter medications or supplements.

	Medication Name	Dosage (mg)	Frequency (x taken per day)	Tablet / Capsule / Ointment / Fluid
1
2
3
4
5
6
7
8
9
10

	Medication Name	Quantity (30 Days)	Dosage (mg)	Frequency (per day)	Tablet Capsule Ointment Fluid
11
12
13
14
15
16
17
18
19
20