FREE INDIVIDUAL MEDICARE REPORT
We provide our clients with cost-saving options!
Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
I'm ready to start saving money on my Medicare Coverage...
I am
*
MALE
FEMALE
My current age is:
*
ex: 67
My Zip Code is:
*
ex: 68661
Tobacco User
*
YES
NO
I'm Currently on Medicare
*
YES
NO
My Current Medicare Supplement:
Medicare Supplement Monthly Premium:
$ /month or Quarter or Year
Medicare Supplement Plan Type:
F, G, N, C, etc.
2018 Medicare Part D Plan Name:
Pharmacy Preference (list up to 2)
CVS and Walgreens
My Current Prescriptions are:
Lisinopril 20mg daily - Blood Pressure
My spouse is on Medicare too...
My spouse is on Medicare too!
*
YES
NO
My Spouse is:
*
MALE
FEMALE
My spouse's age is:
*
ex: 67
Tobacco User
*
YES
NO
Spouse's Medicare Supplement:
Medicare Supplement Monthly Premium:
$ /month or Quarter or Year
Medicare Supplement Plan Type:
F, G, N, C, etc.
2018 Medicare Part D Plan Name:
Pharmacy Preference (list up to 2)
CVS and Walgreens
Spouse's Current Prescriptions are:
Lisinopril 20mg daily - Blood Pressure
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