PRESCRIPTION DRUGS Name* Email* Phone Number* Zip Code* What is Your Preferred Pharmacy?* RX Drug Search Medication # Drug Name Dosage Times Per Day Generic / Brandname Rx Medication 1 GenericBrandname Rx Medication 2 GenericBrandname Rx Medication 3 GenericBrandname Rx Medication 4 GenericBrandname Rx Medication 4 GenericBrandname Rx Medication 6 GenericBrandname Rx Medication 7 GenericBrandname Rx Medication 8 GenericBrandname Rx Medication 9 GenericBrandname Rx Medication 10 GenericBrandname Rx Medication 11 GenericBrandname Rx Medication 12 GenericBrandname Rx Medication 13 GenericBrandname Rx Medication 14 GenericBrandname Rx Medication 15 GenericBrandname Rx PLEASE LIST YOUR DOCTOR HERE Primary Care Physician* Address* Specialist 1 Address Specialist 2 Address Specialist 3 Address Specialist 4 Address Specialist 5 Address Questions, comments additional medications By completing this form you agree that a licensed insurance agent may contact you by phone, mail or email to answer any questions you have regarding Medicare Advantage or Medicare Supplement plans. This is a solicitation for insurance. Δ