Medicare Prescription Drug Plan Comparison Request for 2027

If you have original Medicare, Montgomery County SHIP can help you select the Medicare Prescription Drug plan that best meets your needs for 2027. 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.

Email My Results

Note: If you want results emailed to you, SHIP will do so by secure email to protect your privacy. You will be instructed how to set up an account and set a password.

Email

Street Address

Apartment Number

City

State

Postal/Zip Code

Telephone Number

Include Area Code, NO hyphens or spaces

If needed, may we leave results in a voicemail message on this phone?

Alternate Telephone Number

Include Area Code, NO hyphens or spaces

If needed, may we leave results in a voicemail message on this phone?

Your Pharmacies

List 2 retail pharmacies where you would be willing to fill your prescriptions (e.g., CVS, Giant, Walmart).

Pharmacy 1

Pharmacy 2

Insurance Information

Are you new to Medicare Part D?

If you are new to Medicare Part D, when will your coverage start?

MM/YY

Caution: Some retiree plans may cancel a retiree's medical and drug coverage if the retiree joins a Medicare plan. If you have retiree coverage from an employer, ask their HR department about this before enrolling in Part D.

If you are not new to Medicare Part D, please identify your current 2026 Medicare Drug Plan

If your plan is not listed above, enter it here:

I have Extra Help (LIS) or Medicaid. Eligibility depends on your income and assets. Contact SHIP for more information.

I am enrolled in the Maryland Senior Prescription Drug Plan Assistance Program (SPDAP). Eligibility depends on your income. There is no asset limit. Contact SHIP for more information.

Your prescription drugs

Are you currently taking prescription drugs?

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).
Indicate whether you can take the generic 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

Drug #1: Can you take the generic version?

Drug #1 Drug Form

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

Drug #2: Can you take the generic version?

Drug #2 Drug Form

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

Drug #3: Can you take the generic version?

Drug #3 Drug Form

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

Drug #4: Can you take the generic version?

Drug #4 Drug Form

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

Drug #5: Can you take the generic version?

Drug #5 Drug Form

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

Drug #6: Can you take the generic version?

Drug #6 Drug Form

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

Drug #7: Can you take the generic version?

Drug #7 Drug Form

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

Drug #8: Can you take the generic version?

Drug #8 Drug Form

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

Drug #9: Can you take the generic version?

Drug #9 Drug Form

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

Drug #10: Can you take the generic version?

Drug #10 Drug Form

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

Drug #11: Can you take the generic version?

Drug #11 Drug Form

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

Drug #12: Can you take the generic version?

Drug #12 Drug Form

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

Drug #13: Can you take the generic version?

Drug #13 Drug Form

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

Drug #14: Can you take the generic version?

Drug #14 Drug Form

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

Drug #15: Can you take the generic version?

Drug #15 Drug Form

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

Drug #16: Can you take the generic version?

Drug #16 Drug Form

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

Drug #17: Can you take the generic version?

Drug #17 Drug Form

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

Drug #18: Can you take the generic version?

Drug #18 Drug Form

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

Drug #19: Can you take the generic version?

Drug #19 Drug Form

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

Drug #20: Can you take the generic version?

Drug #20 Drug Form

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

Drug #21: Can you take the generic version?

Drug #21 Drug Form

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

Drug #22: Cannot take generic.

Drug #22 Drug Form

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

Drug #23: Can you take the generic version?

Drug #23 Drug Form

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

Drug #24: Can you take the generic version?

Drug #24 Drug Form

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

Drug #25: Can you take the generic version?

Drug #25 Drug Form

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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