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Send Us Your Prescriptions:

Please submit your prescriptions below and we will use a Prescription Drug Tool to find the RX Part D Plan with the lowest annual total cost and contact you with a suggestion.

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Name
 
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Please enter the county in which you live. Example: Fulton, Tarrant, etc.

Please select the state where you are located

Please enter your zip code.

Please enter your birthday (MM/DD/YYYY)

             Example: Lipitor Example:10 mg Example: 1 X day
If you select other dosage please explain in the additional comments section below. Please also submit a separate request for your spouse.

Medication #1   Dosage                 Frequency 

Medication #2   Dosage                 Frequency 

Medication #3   Dosage                 Frequency 

Medication #4   Dosage                 Frequency 

Medication #5   Dosage                 Frequency 

Medication #6   Dosage                 Frequency 

Medication #7   Dosage                 Frequency 

Medication #8   Dosage                 Frequency 

Medication #9   Dosage                 Frequency 

Medication #10 Dosage                 Frequency 

Additional Comments About Your Prescriptions/Or Questions:
 



                                 
 

 


 


 


Publications:

Medicare at a Glance

Medicare & You

Choosing A MediGap Policy

Medicare's Guide to Preventive Services

Your Guide to What Medicare Part A & B Covers



 

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