Medicare Prescription Drug Plan Comparison Request for 2026

If you have original Medicare, Montgomery County SHIP can help you select the Medicare Prescription Drug plan that best meets your needs for 2026. To compare your options, we need information about the pharmacies you are willing to use and the drugs you take routinely.

For assistance with Medicare Advantage plans, please call our office at 301-255-4250.

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.

YES (Email is required)NO

Email

Street Address*

Apartment Number

City*

State*

Postal/Zip Code*

Telephone Number*

Include Area Code, NO hyphens or spaces

YesNo

Alternate Telephone Number

Include Area Code, NO hyphens or spaces

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 2026 and other plans.

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:

YESNO

Your prescription drugs

YesNo

If you do not currently take prescription drugs, leave the Drug Name field blank and click on submit. We will send you information on the lowest cost plans available.

If you take 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).
Choose "Cannot take generic" if you must use the brand-name version of the medication.
For "other than pills", be specific about the form and how many tubes/bottles/packs/inhalers/etc. you purchase per month or per year.

Prescription #1 Full Name of Drug

Leave blank if you do not currently take prescription drugs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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