Be ready to provide:

• Full names and dosages of all current prescriptions
• Information about your existing coverage
• Your contact information

*All information entered here is strictly confidential, secure, and will only be used to provide cost information to you about your specific prescriptions and Medicare Part D Prescription drug plans.

I understand that this form constitutes a request for a licensed Medicare agent to review and compare my specific list of current prescription drugs 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, I 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.

*ALL REQUESTS WILL BE PROCESSED IN THE ORDER RECEIVED. Processing times will vary, based on demand.*

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.