Client Drug List for Annual Enrollment

Please complete the form below with your current medications, preferred pharmacies, and any recent changes. This information will help us review your options for the upcoming Annual Enrollment Period.

Name(Required)

Phone Number(Required)

Email Address

County you live in:(Required)

Address(Required)

Your current medicare plan:(Required)

Do you receive extra help?(Required)

Yes

I’m not sure

Medication(Required)

Medication Name (example: Lipitor)

Dosage (example: 20mg)

Frequency (example: Once Daily)

Pharmacies you prefer: Please list at least 3.(Required)

Reviewing your pharmacy is just as important as reviewing your medications. We’ll make sure your preferred pharmacies are listed as standard or preferred with the appropriate carrier.

Changes:

Address

Household Income

Other (please list)

Changes:

Call Today

(304) 374-4196

Client Drug List for Annual Enrollment

Client Drug List for Annual Enrollment

Our Providers