Part D Application

PROVIDING INFORMATION IS COMPLETELY OPTIONAL & WILL BE USED SOLELY TO PROVIDE ASSISTANCE REGARDING MEDICARE SUPPLEMENT / DRUG CARD / MEDICARE ADVANTAGE OPTIONS

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Current Medications

List your Prescription medications here.  DO NOT list Over The Counter medications.  Provide the exact mediation name – If you take generics list generics, if you take brand name list the brand name.  List the name of the medication , the dosage that is prescribed, number of pills/tubes/inhalers you pick up at one time, and how often you fill (pick up) that medication. Must specify whether it is a tablet (tab) or Capsule (Cap).  Do not write PRN as we cannot guess at your medication frequency.  We need a time period to be able to run the quote.  Examples:

 

Metoprolol Tartrate ER, 50mg, 30 tablets monthly

Clobetasol Propionate Ointment, 0/5%, 60GM Tube 1 every 3 months

Albuterol Sulfate inhaler, 108MCG, 6.7 gm inhaler, 1 a year