Submit a Prescription Drug List 

Are you open to having your prescriptions mailed to you, if it saves you additional money?
Do you receive Social Security EXTRA help?
If Yes, do you receive
Prescription Drug List
Drug Name
Tablet or Capsule?
Dosage (MG Amount)
Times Per Day
Refill Length (30, 60, 90 Days?)
(click the "+" button to add additional drugs)
List of Doctors
First Name
Last Name
(click the "+" button to add additional doctors)
By 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.