2027 Prescription Drug Plan Review

To request a review of your Medicare prescription drug plan, please download our form (PDF of Excel) or complete the online form below.

  • Before completing the form, please have all current prescription medication information on hand (name, dosage, frequency, etc).
  • After we receive your information we will contact you in October to discuss plan options and details.
  • All information will be treated as confidential and used solely for Medicare enrollment purposes through our office.
PDP Printable Forms

DOWNLOAD PDF  

DOWNLOAD XLSX  
PDP Online Form

Each field marked with (*) is required

Name: *
Address (Street, City, ZIP): *
County: *
Home Phone:
Cell Phone:
Email Address *
DOB: *
Spouses 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? *
Preferred Method To Receive Your PDP Results? *
Interested In Learning About Medicare Advantage Plans?
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? *
Do you currently take prescription medications? *
Physician 1 and Location
Physician 2 and Location
Physician 3 and Location
Physician 4 and Location
Physician 5 and Location


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)
Medications 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)
Coupons Used For This Medication? (e.g. GoodRx)
Generic (Y / N)
Medications 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 3

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)
Medications 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 4

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)
Medications 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)


 

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