Medicare Part C/D Review Request
Check Medicare Insurance Choices for the upcoming year. Medicare Advantage & Prescription Drug Plans will be changing their premiums, deductibles, co-pays and formularies for next year. October 15 through December 7 is your opportunity to make changes to your plan selections for the upcoming year. Submit a complete prescription medication list and you will receive personalized information about the plans by mail or email. Next year's plan information should be available October 15th at www.medicare.gov.
Open to Washington County residents only.
Contact Info
Insurance Coverage
Medicare Part A Start Date:
Medicare Part B Start Date:
Current Prescription or Advantage Plan - SELECT ONE PLAN
(Select insurance company then select your plan in the corresponding dropdown box)
* If you are not sure what plan you have please check the contract ID number on your plan card.
Aetna
Anthem BCBS
Cigna
Clear Spring
Community Care
Elixir
Humana
ICare
Molina
Mutual of Omaha
My Choice Wisconsin Health Plan
Network Health
Quartz
SilverScript
United Healthcare / AARP
Wellcare
Wellcare by Allwell
Other (Employer Group Plan, Retiree coverage, WI SeniorCare, Veterans Benefits)
Pharmacy Selection
Plan reviews include mail order pricing and the pricing for up to 4 local pharmacies.
Local Pharmacy Preference Select up to 4 pharmacies.
*Note: if no pharmacy is selected we will default to Walgreens
Mail Order
Drug List
Please provide complete medication list including NAME, DOSAGE and HOW OFTEN TAKEN for each drug. Additional drugs can be included in the comments section below.
(If prescription is taken "as needed" advise how often script is filled ie: every 3 months, once per year, etc.)
NAME - DOSAGE - FREQUENCY
Example: Lisinopril - 10MG - 1 per day
Prescription 1:
Prescription 2:
Prescription 3:
Prescription 4:
Prescription 5:
Prescription 6:
Prescription 7:
Prescription 8:
Prescription 9:
Prescription 10:
Prescription 11:
Prescription 12:
Prescription 13:
Prescription 14:
Prescription 15:
Comments
Please provide any special instructions or additional medications in the comments section. Please feel free to also include any specific questions or comments you may have in the comment box below.
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