Be ready to provide:

• Full names, dosages, and quantities of all current prescription medications
• Your DOB, phone number, and email address

I understand that this form constitutes a request for a licensed Medicare agent to review and compare my specific list of current prescriptions and their coverage under available Medicare Part D plans. I understand that completing this form does not constitute an enrollment and that enrollment eligibility is determined by Medicare. By providing this information and submitting this form, you agree to be contacted by an authorized representative or licensed insurance agent to answer questions and provide additional information about Medicare Advantage, Part D, or Medicare Supplement insurance plans.

DUE TO FEDERAL LAW, NO 2024 PRESCRIPTION PLAN INFORMATION CAN BE DISCUSSED PRIOR TO OCTOBER 1ST, 2023. ALL REQUESTS SUBMITTED PRIOR TO OCTOBER 1ST WILL BE HELD FOR ANALYSIS UNTIL PLAN INFORMATION IS RELEASED AND FEDERAL LAW ALLOWS.

• *All information submitted on this website is strictly confidential, secure, and will only be used to provide cost information to you about your specific prescriptions and applicable Medicare insurance plans.
• For additional information regarding Medicare and Part D drug coverage, such as the Late Enrollment Penalty, please visit Medicare.gov or call 1-800-Medicare.