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! Please enable JavaScript in your browser to complete this form.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 throughName 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 Name1. Medication Dosage1. Medication Quantity (daily, weekly, or monthly)2. Medication Name2. Medication Dosage2. Medication Quantity (daily, weekly, or monthly)3. Medication Name3. Medication Dosage3. Medication Quantity (daily, weekly, or monthly)4. Medication Name4. Medication Dosage4. Medication Quantity (daily, weekly, or monthly)5. Medication Name5. Medication Dosage5. Medication Quantity (daily, weekly, or monthly)6. Medication Name6. Medication Dosage6. Medication Quantity (daily, weekly, or monthly)7. Medication Name7. Medication Dosage7. Medication Quantity (daily, weekly, or monthly)8. Medication Name8. Medication Dosage8. Medication Quantity (daily, weekly, or monthly)9. Medication Name9. Medication Dosage9. Medication Quantity (daily, weekly, or monthly)10. Medication Name10. Medication Dosage10. Medication Quantity (daily, weekly, or monthly)11. Medication Name 11. Medication Dosage 11. Medication Quantity (daily, weekly, or monthly) 12. Medication Name 12. Medication Dosage12. Medication Quantity (daily, weekly, or monthly)13. Medication Name 13. Medication Dosage13. Medication Quantity (daily, weekly, or monthly)14. Medication Name 14. Medication Dosage14. Medication Quantity (daily, weekly, or monthly)15. Medication Name15. Medication Dosage15. Medication Quantity (daily, weekly, or monthly)CommentSUBMIT