Larry Part D – Medicare Medications List

List Your Medications Below

Please list your medications below so that I can prepare a customized Drug Plan Analysis for you. I will shop all available options!

Your Name *

Your Phone *

Your Email *

Your Preferred Pharmacy -1st choice- (You can indicate mail order)

Your Preferred Pharmacy -2nd choice- (You can indicate mail order)

Name of the Insurance Company that your drug coverage is through

Name of the actual plan ( some companies have up to 6 plans) Please look at your card or plan info that was mailed to you!

CHECK HERE IF YOU DO NOT TAKE ANY MEDICATIONS (Then scroll down and click SUBMIT BUTTON)

INSTRUCTIONS:

Vitamins & Supplements: Do not list these if they are available over the counter. Medicare will not cover them. Medicare covers very few supplements.

Creams & Liquids: List the strength (dosage) and the size of the container (bottle, tube or jar) that it comes in. Then indicate how many per month.

Insulin: Indicate if you use syringes or pens. If you use syringes indicate the dosage and how many vials per month. If you use pens, provide the dosage and how many pens per month.

1. Medication Name

1. Medication Dosage

1. Medication Quantity (daily, weekly, or monthly)

2. Medication Name

2. Medication Dosage

2. Medication Quantity (daily, weekly, or monthly)

3. Medication Name

3. Medication Dosage

3. Medication Quantity (daily, weekly, or monthly)

4. Medication Name

4. Medication Dosage

4. Medication Quantity (daily, weekly, or monthly)

5. Medication Name

5. Medication Dosage

5. Medication Quantity (daily, weekly, or monthly)

6. Medication Name

6. Medication Dosage

6. Medication Quantity (daily, weekly, or monthly)

7. Medication Name

7. Medication Dosage

7. Medication Quantity (daily, weekly, or monthly)

8. Medication Name

8. Medication Dosage

8. Medication Quantity (daily, weekly, or monthly)

9. Medication Name

9. Medication Dosage

9. Medication Quantity (daily, weekly, or monthly)

10. Medication Name

10. Medication Dosage

10. Medication Quantity (daily, weekly, or monthly)

11. Medication Name

11. Medication Dosage

11. Medication Quantity (daily, weekly, or monthly)

12. Medication Name

12. Medication Dosage

12. Medication Quantity (daily, weekly, or monthly)

13. Medication Name

13. Medication Dosage

13. Medication Quantity (daily, weekly, or monthly)

14. Medication Name

14. Medication Dosage

14. Medication Quantity (daily, weekly, or monthly)

15. Medication Name

15. Medication Dosage

15. Medication Quantity (daily, weekly, or monthly)

Phone