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  • Welcome to our drug plan recommendation online form.

    • Please answer all questions.   
    • Your recommendation will be ready in 7 business days.  
    • Click here for our disclaimer.
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  • Your Name: {namerequired1}
    Best Number to Reach You: {phoneNumber} 
    Can We Send You Text Messages? {permissionTo1773}
    Do you have an email address? {emailAddress1285}
    Email Address: {emailAddress1282}
    Zip Code: {zipCode5}
    Local County: {localCounty}
    Preferred Pharmacy: {preferredPharmacy}
    Current 2020 Drug Plan: {whatDrug1774}

     

  • Summary of Prescription Drug #1:

    • Name of Medication: {nameOf}
    • Version:  {whatVersion625}
    • Looks Like:  {whatDoes}
    • Dosage / Strength:  {whatIs}
    • You Take: {iNeed845}{howOften}
    • You Need This Much for a 30-day Supply:  {quantityNeeded}
  • Summary of Prescription Drug #2:

    • Name of Medication: {nameOf1507}
    • Version:  {whatVersion}
    • Looks Like:  {whatDoes1509}
    • Dosage / Strength:  {whatIs1510}
    • You Take:  {iNeed} {howOften1512}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1513}
  • Summary of Prescription Drug #3:

    • Name of Medication: {nameOf1519}
    • Version:  {whatVersion1520}
    • Looks Like:  {whatDoes1521}
    • Dosage / Strength:  {whatIs1522}
    • You Take:  {iNeed1523} {howOften1524}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1525}
  • Summary of Prescription Drug #4:

    • Name of Medication: {nameOf1531}
    • Version:  {whatVersion1532}
    • Looks Like:  {whatDoes1533}
    • Dosage / Strength:  {whatIs1534} {iNeed1535}
    • You Take:  {howOften1536}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1537}
  • Summary of Prescription Drug #5:

    • Name of Medication: {nameOf1543}
    • Version:  {whatVersion1544}
    • Looks Like:  {whatDoes1545}
    • Dosage / Strength:  {whatIs1546}
    • You Take:  {iNeed1547} {howOften1548}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1549}
  • Summary of Prescription Drug #6:

    • Name of Medication: {nameOf1555}
    • Version:  {whatVersion1556}
    • Looks Like:  {whatDoes1557}
    • Dosage / Strength:  {whatIs1558}
    • You Take:  {iNeed1559} {howOften1560}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1561}
  • Summary of Prescription Drug #7:

    • Name of Medication:  {nameOf1567}
    • Version:  {whatVersion1568}
    • Looks Like:  {whatDoes1569}
    • Dosage / Strength:  {whatIs1570}
    • You Take:  {iNeed1571} {howOften1572}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1573}
  • Summary of Prescription Drug #8:

    • Name of Medication: {nameOf1579}
    • Version:  {whatVersion1580}
    • Looks Like:  {whatDoes1581} 
    • Dosage / Strength:  {whatIs1582}
    • You Take:  {iNeed1583} {howOften1584}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1585}
  • Summary of Prescription Drug #9:

    • Name of Medication:  {nameOf1591}
    • Version:  {whatVersion1592}
    • Looks Like:  {whatDoes1593}
    • Dosage / Strength:  {whatIs1594}
    • You Take:  {iNeed1595} {howOften1596}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1597}
  • Summary of Prescription Drug #10:

    • Name of Medication:  {nameOf1603}
    • Version:  {whatVersion1604}
    • Looks Like:  {whatDoes1605}
    • Dosage / Strength:  {whatIs1606}
    • You Take:  {iNeed1607} {howOften1608}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1609}
  • Summary of Prescription Drug #11:

    • Name of Medication: {nameOf1615}
    • Version:  {whatVersion1616}
    • Looks Like:  {whatDoes1617}
    • Dosage / Strength:  {whatIs1618}
    • You Take:  {iNeed1619} {howOften1620}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1621}
  • Summary of Prescription Drug #12:

    • Name of Medication: {nameOf1627}
    • Version:  {whatVersion1628}
    • Looks Like:  {whatDoes1629}
    • Dosage / Strength:  {whatIs1630}
    • You Take:  {iNeed1631} {howOften1632}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1633}
  • Summary of Prescription Drug #13:

    • Name of Medication: {nameOf1639}
    • Version:  {whatVersion1640}
    • Looks Like:  {whatDoes1641}
    • Dosage / Strength:  {whatIs1642}
    • You Take:  {iNeed1643} {howOften1644}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1645}
  • Summary of Prescription Drug #14:

    • Name of Medication: {nameOf1651}
    • Version:  {whatVersion1652}
    • Looks Like:  {whatDoes1653}
    • Dosage / Strength:  {whatIs1654}
    • You Take:  {iNeed1655} {howOften1656}
    • You Need This Much for a 30-day Supply:  {quantityNeeded1657}
  • Summary of Prescription Drug #15:

    • Name of Medication: {nameOf1663}
    • Version: {whatVersion1664}
    • Looks Like: {whatDoes1665}
    • Dosage / Strength: {whatIs1666}
    • You Take: {iNeed1667} {howOften1668}
    • You Need This Much for a 30-day Supply: {quantityNeeded1669}
  • I'm ready to get a drug plan recommendation based on this list of medications. 

    *If you do not take any medications, this will be blank.

    Please review and then scroll down and press "SUBMIT DRUG LIST".

    ====================================

    Your current list of medications:

    1. {nameOf} {whatIs} {whatDoes}
    2. {nameOf1507} {whatIs1510} {whatDoes1509}
    3. {nameOf1519} {whatIs1522} {whatDoes1521}
    4. {nameOf1531} {whatIs1534} {whatDoes1533}
    5. {nameOf1543} {whatIs1546} {whatDoes1545}
    6. {nameOf1555} {whatIs1558} {whatDoes1557}
    7. {nameOf1567} {whatIs1570} {whatDoes1569}
    8. {nameOf1579} {whatIs1582} {whatDoes1581}
    9. {nameOf1591} {whatIs1594} {whatDoes1593}
    10. {nameOf1603} {whatIs1606} {whatDoes1605}
    11. {nameOf1615} {whatIs1618} {whatDoes1617}
    12. {nameOf1627} {whatIs1630} {whatDoes1629}
    13. {nameOf1639} {whatIs1642} {whatDoes1641}
    14. {nameOf1651} {whatIs1654} {whatDoes1653}
    15. {nameOf1663} {whatIs1666} {whatDoes1665}
  • Should be Empty: