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Enter Your Medications

To review your PART D Drug Plan, We'll need the following information.

Note – We don’t require your phone #!! We aren’t those people calling after hours on your cell phones hounding you to talk with us. E-mail IS required, however, so that we can contact you. But, you can delete that pretty easily. *** Please fill out all areas of the form so that we don’t have to reconnect for more info. Thanks!

  • Please list all CURRENT medications, dosage and frequency taken (do not include vitamins or over the counter items). Example: Atorvastatin, 20mg, 1 per day

  • The Fine Print: We represent (meaning that we are contracted with, are agents for and our compensated by the carrier) some Part D carriers but not all. If we are NOT contracted, we can help to enroll you via In those cases, you may have to contact the particular carrier directly for additional questions and/or service issues. Just a heads up! (PS - no carrier is great with service so be prepared!)

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