2026 AEP Review

2026 AEP Review Form

If you would like to review your Prescription Drug Plan or Medicare Advantage Plan for 2026, please complete the entire form and submit it to us as soon as possible. We will get back to you as soon as we do our review, which will be after October 15th.
Insured Name*

First NameLast Name
Current Address (optional - only if you've moved)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What County Are You In
Preferred Phone Number*
Preferred Email*
example@example.com
You must verify your email address before proceeding.
Your email address will not be sold or distributed.
ANNUAL ENROLLMENT CONTACT PREFERENCE: Select one option below.

I would like to be contacted by phone call. By checking this box, I understand that MC Insurance Services will contact me by phone call during Annual Enrollment, October-December to review my coverage for the upcoming year.I would like to be contacted by email. By checking this box, I understand that MC Insurance Services will contact me by email during Annual Enrollment, October-December to review my coverage for the upcoming year.

CURRENT PLAN INFORMATION

For current clients, we have this information on file. If you've changed policies or new to us, please let us know what plan you're currently on. This will help us make our recommendation for review.
What is Your Current Rx Plan?
What is Your Preferred Pharmacy(s)?
Do you receive Extra Help, Medicaid, or VA Benefits?

Extra HelpMedicaidVA BenefitsOther
Notes:

PRESCRIPTION INFORMATION

Please include details in the notes section regarding prescriptions that are occasionally filled, have varying quantities, or come in multi-packs. When listing prescriptions in a patient or pharmaceutical assistance program, please include details in the notes section.

Rx Drug Lookup *Please be sure to fill out ALL information on your Rx drugs or we will NOT be able to review for 2026.

	Drug Name	Dosage (MG Amount)	Prescribed Quantity (per month)	Tablet/ Capsule/Other
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Medication 11
Medication 12
Medication 13
Medication 14
Medication 15
Medication 16
Medication 17
Medication 18
Medication 19
Medication 20

Doctor Lookup

Agreement to Contact
Questions, comments or additional medications
Please check your email for Scope of Appointment form 1-2 business days after you submit your Rx form.

For compliance, we will need this before we can discuss or review any plans with you. Thank you!
Signature

Clear
By providing my e-mail address or telephone number, I agree to allow a licensed insurance agent to call and/or e-mail me regarding information related to Medicare Advantage Plans, Prescription Drug Plans, Medicare Supplement Insurance. You can send in your written desire to not be contacted at any time. This is a solicitation for insurance.
Should be Empty:

PRESCRIPTION INFORMATION