Drug List

Drug List

I am voluntarily sharing this info with Imagine Insurance Advisors so they can make a recommendation. I understand Imagine will only recommend plans that they can support and receive compensation for. For info on all plans available, I can visit Medicare at www.Medicare.gov or call 1-800-MEDICARE 1-800-633-4227.
Your first and last name*
First and Last Name
Date*

MonthDayYear
Date
Phone Number*
Preferred Pharmacies*
INSTRUCTIONS. Please read: Do not include over-the-counter meds or vitamins. Write the entire name of your medication exactly how it appears on the RX label. If cream/gel/solution/drop, include the size of the bottle or tube in the strength column.

If you take insulin, scroll down to the insulin section and add your insulin there.

Once you have entered all your medications, scroll down to the bottom to submit your list.
Drug 1
Name of the drug from bottle
Drug 1 - Strength
Ie. 40mg or 12.5/20 mg. If you take a cream or ointment, but the size of the tube. If drops the how many ml is the bottle.
Drug 1 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 1 - Number per day
Number taken per day
Drug 1 - Do you fill this every 90 days?
Drug 1 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 2
Name of the drug on the bottle
Drug 2 - Strength
Ie. 40mg or 20/12.5mg
Drug 2 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 2 - Number per day
Number taken per day.
Drug 2 - Do you fill this every 90 days?
Drug 2 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 3
Name of the drug on the bottle
Drug 3 - Strength
Ie. 40mg or 20/12.5mg
Drug 3 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 3 - Number per day
Number taken per day.
Drug 3 - Do you fill this every 90 days?
Drug 3 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 4
Name of the drug on the bottle
Drug 4 - Strength
Ie. 40mg or 20/12.5mg
Drug 4 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 4 - Number per day
Number taken per day.
Drug 4 - Do you fill this every 90 days?
Drug 4 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 5
Name of the drug on the bottle
Drug 5 - Strength
Ie. 40mg or 20/12.5mg
Drug 5 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 5 - Number per day
Number taken per day.
Drug 5 - Do you fill this every 90 days?
Drug 5 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 6
Name of the drug on the bottle
Drug 6 - Strength
Ie. 40mg or 20/12.5mg
Drug 6 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 6 - Number per day
Number taken per day.
Drug 6 - Do you fill this every 90 days?
Drug 6 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 7
Name of the drug on the bottle
Drug 7 - Strength
Ie. 40mg or 20/12.5mg
Drug 7 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 7 - Number per day
Number taken per day.
Drug 7 - Do you fill this every 90 days?
Drug 7 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 8
Name of the drug on the bottle
Drug 8 - Strength
Ie. 40mg or 20/12.5mg
Drug 8 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 8 - Number per day
Number taken per day.
Drug 8 - Do you fill this every 90 days?
Drug 8 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 9
Name of the drug on the bottle
Drug 9 - Strength
Ie. 40mg or 20/12.5mg
Drug 9 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 9 - Number per day
Number taken per day.
Drug 9 - Do you fill this every 90 days?
Drug 9 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 10
Name of the drug on the bottle
Drug 10 - Strength
Ie. 40mg or 20/12.5mg
Drug 10 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 10 - Number per day
Number taken per day.
Drug 10 - Do you fill this every 90 days?
Drug 10 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 11
Name of the drug on the bottle
Drug 11 - Strength
Ie. 40mg or 20/12.5mg
Drug 11 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 11 - Number per day
Number taken per day.
Drug 11 - Do you fill this every 90 days?
Drug 11 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 12
Name of the drug on the bottle
Drug 12 - Strength
Ie. 40mg or 20/12.5mg
Drug 12 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 12 - Number per day
Number taken per day.
Drug 12 - Do you fill this every 90 days?
Drug 12 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 13
Name of the drug on the bottle
Drug 13 - Strength
Ie. 40mg or 20/12.5mg
Drug 13 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 13 - Number per day
Number taken per day.
Drug 13 - Do you fill this every 90 days?
Drug 13 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 14
Name of the drug on the bottle
Drug 14- Strength
Ie. 40mg or 20/12.5mg
Drug 14 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 14 - Number per day
Number taken per day.
Drug 14 - Do you fill this every 90 days?
Drug 14 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
Drug 15
Name of the drug on the bottle
Drug 15- Strength
Ie. 40mg or 20/12.5mg
Drug 15 - How often taken?
How often do you fill this medication? If as needed, put how many times you fill it in the comments at the end of the form.
Drug 15 - Number per day
Number taken per day.
Drug 15 - Do you fill this every 90 days?
Drug 15 - Form of drug. Please pick one.
If you pick Other, please put the form in the comments at the end.
If you have more medications, please fill out an additional drug list and where you put your name, add ADDITIONAL MEDS to your name.
Insulin Section

Write the name as it appears on you prescription. We cannot translate the number of units, so make sure you tell us if it is bottles or pens and how many bottles or pens you use per month.
Insulin 1. Ie. Lantus Solostar
Bottles or Pens?
Number of bottles/pens per month.
Insulin 2. Ie. Novolog
Bottles or Pens?
Number of Bottles or Pens per month.
Additional information we might need to know.
If you said "As Needed" for the taken daily, please tell us how often you fill it. If you put "Other" on a medication form, please enter it here.
Should be Empty:

Drug List

Insulin Section