Thank you for your interest in Part D Prescription Plans. We recommend submitting your prescriptions for review
every
year.
You only have the chance to do this during the open enrollment period between the dates of November 15th and December 31st so be sure to submit yours for a FREE Part D prescription review before it's too late.
If you prefer to fax or mail your form in,
click here
to download a copy of the form. You will need Adobe Reader to open this document. If it does not open,
click here
to download a free copy of the program.
Be sure to fill out both sections of the form if your spouse is requesting a Part D review as well.
There is no need to fill out this form if you currently have VA, PACE or Group Coverage. Always come to us first with any questions and feel free to
contact us
for a status anytime, it's never a bother.
We will do our best to have a response to you within 3 weeks.
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Name
Address 1
Address 2
City
State
Zip Code
Phone Number
Agent's Name
Part D Plan you are currently on
Monthly Premium
Current Health Insurance Plan
Is this group coverage?
Yes
No
Did you go into the "Donut Hole" in 2006?
Yes
No
Prescrition Name
Dosage
Times per day taken
If available use a generic?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Spouse's Name (if only submitting for one person
)
Address 1 (if different from above)
Address 2
City
State
Zip Code
Phone Number (if different from above)
Agent's Name
Part D Plan you are currently on
Monthly Premium
Current Health Insurance Plan
Is this group coverage?
Yes
No
Did you go into the "Donut Hole" in 2006?
Yes
No
Prescrition Name
Dosage
Times per day taken
If available use a generic?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Thank you for submitting your prescriptions for Part D Open Enrollment.
Click below to submit your information to our agents.