Pdp Review Sheet 2010 V2
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YOUNG’S INSURANCE SERVICES, INC. 2950 Felton Rd. * Suite 204 * East Norriton, PA 19401 * Office # 610-275-7923 * Fax # 610-275-7925 E-Mail me at [email protected] * View my website at www.yourmedicarespecialist.com
Medicare Part D/MA Prescription Annual Review Sheet (please submit one form per person) Drug Plans, premiums, co-pays, and formularies change each year from company to company. If you would like us to review your current Rx plan through the Medicare Plan Finder, you may list out your prescriptions below. I will contact you within a few weeks with the results. This is a complimentary service offered to our clients by our agency and is completely optional.
Your Name:
Your Address:
Your Phone #
Your Agent’s Name:
James Long
What company do you currently use for your Rx Plan? Do you use mail order?
Are you enrolled in PACE or PACENET? Did you go into the donut hole?
Can you take generics?
(*Please note below if name brand is necessary)
What company do you have for health insurance? Prescription Name (Include XL, CR, XR, HCT etc.) EXACT SPELLING NECESSARY!
Dosage
Times taken Prescription Name (Include XL, CR, XR, HCT etc.)
EXACT SPELLING NECESSARY!
a day
1)
11)
2)
12)
3)
13)
4)
14)
5)
15)
6)
16)
7)
17)
8)
18)
9)
19)
10)
20)
Dosage
Times taken a day
Medicare Part D/MA Prescription Annual Review Sheet (please submit one form per person) Drug Plans, premiums, co-pays, and formularies change each year from company to company. If you would like us to review your current Rx plan through the Medicare Plan Finder, you may list out your prescriptions below. I will contact you within a few weeks with the results. This is a complimentary service offered to our clients by our agency and is completely optional.
Your Name:
Your Address:
Your Phone #
Your Agent’s Name:
James Long
What company do you currently use for your Rx Plan? Do you use mail order?
Are you enrolled in PACE or PACENET? Did you go into the donut hole?
Can you take generics?
(*Please note below if name brand is necessary)
What company do you have for health insurance? Prescription Name (Include XL, CR, XR, HCT etc.) EXACT SPELLING NECESSARY!
Dosage
Times taken Prescription Name (Include XL, CR, XR, HCT etc.)
EXACT SPELLING NECESSARY!
a day
1)
11)
2)
12)
3)
13)
4)
14)
5)
15)
6)
16)
7)
17)
8)
18)
9)
19)
10)
20)
Dosage
Times taken a day
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