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Prescription Drug Form
Please Enter Your Contact Information
First Name
*
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*
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Current Policy
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Current Premium
*
Agent Name
Address and traveling
Do you live at a different address between October 15th and December 7th?
*
No
Yes
If yes, please provide the address here:
Do you receive extra help from Medicaid or Social Security?
*
—Please choose an option—
Medicaid
PARTIAL extra help through social security
FULL extra help through social security
Prescription Information
Medication 1
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 2
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 3
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 4
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 5
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 6
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 7
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 8
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 9
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 10
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 11
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 12
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 13
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 14
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Medication 15
Drug Name:
Name Brand or Generic:
Name Brand
Generic
Dosage:
Type:
tablet
capsule
cream
drop
How Many Per Day:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How Often Do You Refill
Other Information
Insulin
Do you take insulin?
*
yes
no
Please List The Types Below
1.
Name of Insulin:
Pen Size:
Mix/Concentration:
Number in Package:
Number Used Per Month:
2.
Name of Insulin:
Pen Size:
Mix/Concentration:
Number in Package:
Number Used Per Month:
Inhalers & Nebulizers
Do you have an inhaler or nebulizer?
*
yes
no
Please List The Types Below
1.
Name of Inhaler or Nebulizer:
Size (GM/ML):
Number Used Per Month:
2.
Name of Inhaler or Nebulizer:
Size (GM/ML):
Number Used Per Month:
Creams, Gels, Ointments, Lotions & Shampoos
Please List The Types Below
1.
Product name:
Product Type:
—Please choose an option—
Cream
Gel
Ointment
Lotion
Shampoo
Solution
Concentration:
Refill Quantity per month/year:
2.
Product name:
Product Type:
—Please choose an option—
Cream
Gel
Ointment
Lotion
Shampoo
Solution
Concentration:
Refill Quantity per month/year:
Pharmacy Information
What Are Your Preferred pharmacies:
If prices are cheaper at another pharmacy in my area, I will change pharmacies:
*
yes
no
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