2024 Prescription Drug Plan Review

Our 2024 PDP review form is available to download (PDF or Excel spreadsheet), or can be completed via the online form below. We recommend only completing the online form on a larger screen (desktop PC or laptop).

All information will be treated as confidential and used solely for Medicare enrollment purposes through our office.

Before completing the form, please have all current prescription medication information on hand (name, dosage, frequency, etc).

Questions? We are here to help! Call our office at 810-534-3008 to speak with an agent.

2024 PDP Printable Form

 
DOWNLOAD PDF  

2024 PDP Online Form

All fields marked with an asterisk ( * ) indicates a required field.

Name: *
Address (Street, City, ZIP): *
County: *
Home Phone:
Cell Phone:
Email Address *
DOB: *
Spouse's Name & DOB: *
Medicare ID#:
Part A Effective Date:
Part B Effective Date:
Current Drug Plan: *
Current Drug Plan Premium Cost: *
What Pharmacy Do You Use? *
Do You Get Your Prescriptions By Mail? *
Are You Willing To Switch Pharmacies If You Can Save Money? *
Do You Travel Internationally? *
Interested In Learning About Medicare Advantage Plans?

Please list all current physicians and their location (include all doctors and specialists, dentists, and chiropractors)

Physician 1 and Location
Physician 2 and Location
Physician 3 and Location
Physician 4 and Location
Physician 5 and Location
Preferred Method To Receive Your PDP Results? *
Interested In Dental, Vision, & Hearing Coverage?: *
Interested In Obtaining Quotes For Home & Auto Insurance? *
Interested In Obtaining Quotes For Life Or Final Expense Insurance? *
Interested In Learning About Financial Planning Services? *
CURRENT MEDICATION LIST

MEDICATION 1

Medication Name
Dosage (e.g. mg or mcg)
Prescribed Frequency (e.g. 2/day or as needed)
Coupons Used For This Medication? (e.g. GoodRx)
Generic (Y / N)
Medication's Form (e.g. capsule, inhaler, etc)
Refill Frequency (e.g. 30 days or 90 days)
Medication Notes (e.g. if your script is for eye drops, include the strength percentage & bottle size)


MEDICATION 2

Medication Name
Dosage (e.g. mg or mcg)
Prescribed Frequency (e.g. 2/day or as needed) med 2 presc freq
Coupons Used For This Medication? (e.g. GoodRx)
Generic (Y / N)
Medication's Form (e.g. capsule, inhaler, etc) med 2 form
Refill Frequency (e.g. 30 days or 90 days) med 2 refil freq
Medication Notes (e.g. if your script is for eye drops, include the strength percentage & bottle size) med 2 notes


MEDICATION 3

Medication Name med name 3
Dosage (e.g. mg or mcg) dosage med 3
Prescribed Frequency (e.g. 2/day or as needed) presc freq med 3
Coupons Used For This Medication? (e.g. GoodRx)
Generic (Y / N) generic med 3
Medication's Form (e.g. capsule, inhaler, etc) med form 3
Refill Frequency (e.g. 30 days or 90 days) refill freq med 3
Medication Notes (e.g. if your script is for eye drops, include the strength percentage & bottle size) med notes 3


MEDICATION 4

Medication Name med name 4
Dosage (e.g. mg or mcg) dosage med 4
Prescribed Frequency (e.g. 2/day or as needed) presc freq med 4
Coupons Used For This Medication? (e.g. GoodRx)
Generic (Y / N) generic med 3
Medication's Form (e.g. capsule, inhaler, etc) med form 4
Refill Frequency (e.g. 30 days or 90 days) refil freq med 4
Medication Notes (e.g. if your script is for eye drops, include the strength percentage & bottle size) med notes 4


MEDICATION 5

Medication Name med name 5
Dosage (e.g. mg or mcg) dosage med 5
Prescribed Frequency (e.g. 2/day or as needed) pres freq med 5
Coupons Used For This Medication? (e.g. GoodRx)
Generic (Y / N) generic med 5
Medication's Form (e.g. capsule, inhaler, etc) meds form 5
Refill Frequency (e.g. 30 days or 90 days) refil presc med 5
Medication Notes (e.g. if your script is for eye drops, include the strength percentage & bottle size) med notes 5


MEDICATION 6

Medication Name med name 6
Dosage (e.g. mg or mcg) dosage med 6
Prescribed Frequency (e.g. 2/day or as needed) presc freq med 6
Coupons Used For This Medication? (e.g. GoodRx)
Generic (Y / N)
Medication's Form (e.g. capsule, inhaler, etc) med form 6
Refill Frequency (e.g. 30 days or 90 days) refill freq med 6
Medication Notes (e.g. if your script is for eye drops, include the strength percentage & bottle size) med notes 6


MEDICATION 7

Enter Field Title
Medication Name med name 7
Dosage (e.g. mg or mcg) dosage med 7
Prescribed Frequency (e.g. 2/day or as needed) pres freq med 7
Coupons Used For This Medication? (e.g. GoodRx)
Generic (Y / N) generic med 7
Medication's Form (e.g. capsule, inhaler, etc) med form 7
Refill Frequency (e.g. 30 days or 90 days) refil freq med 7
Medication Notes (e.g. if your script is for eye drops, include the strength percentage & bottle size) med notes 7

After we receive your information we will contact you in October to discuss plan options and details. We look forward to working with you!

 

SUBMIT

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Let's have a conversation today! Call us to speak with an associate or schedule an appointment online.

 

 

Tyrone Carr & Associates
10299 E. Grand River Ave. Suite K
Brighton, MI 48116