Submit a Prescription Drug List Name(Required)Email(Required) PhoneZip codeWhat is Your Preferred Pharmacy?Are you open to having your prescriptions mailed to you, if it saves you additional money? Yes No Do you receive Social Security EXTRA help? Yes No Medicaid? Yes No If Yes, do you receive Full Partial Any other coverage?Prescription Drug ListDrug NameTablet or Capsule?Dosage (MG Amount)Times Per DayRefill Length (30, 60, 90 Days?) Add Remove(click the "+" button to add additional drugs)List of DoctorsFirst NameLast NameSpecialityCityZipcode Add Remove(click the "+" button to add additional doctors)Comments/Additional Drugs or DoctorsBy completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare plans. This is a solicitation for insurance. Δ
