Standalone Drug Plan Review Form

Enrollment Starts October 15, 2020

IMPORTANT: Medicare Open Enrollment Ends: December 7, 2020

  • This field is for validation purposes and should be left unchanged.
  • MM slash DD slash YYYY

  • LIST OF MEDICATIONS

    Please fill out the list of your current medications including: Name, dosage (mg), Number of Times Taken Per Day in order to get the drug review. Completing this form will not prevent you from enrolling into any plan of your choice for which you are eligible.

  • MEDICATIONS #1

  • Per Day/Month/Year (Circle)

  • MEDICATIONS #2

  • Per Day/Month/Year (Circle)

  • MEDICATIONS #3

  • Per Day/Month/Year (Circle)

  • MEDICATIONS #4

  • Per Day/Month/Year (Circle)

  • MEDICATIONS #5

  • Per Day/Month/Year (Circle)

  • MEDICATIONS #6

  • Per Day/Month/Year (Circle)

  • MEDICATIONS #7

  • Per Day/Month/Year (Circle)

  • MEDICATIONS #8

  • Per Day/Month/Year (Circle)

  • MEDICATIONS #9

  • Per Day/Month/Year (Circle)

  • MEDICATIONS #10


  • MEDICATIONS #11

  • Per Day/Month/Year (Circle)
  • Clear Signature