Medicare Advantage Annual Reviews
Each year, as your agent, we strive to make sure your Medicare Advantage plan is still a great fit. Please complete this form at your earliest convenience if you would like us to complete an annual plan review.
Section 1 - Base
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Section 2 - Prescription Details for Medicare Advantage Plans
Medication(s)
*
Preferred Pharmacy
Optional Pharmacies if Cost Savings Are Available
Section 3 - Medical Providers to Ensure Networks of Coverage
Please list the names for any providers you’ve seen in the last 12 months
Primary Doctor
Specialist Doctors
*
What do you currently like or dislike about your plan?
0/300
Are there any areas of benefits you would like us to focus on in our review: For example, dental, vision, hearing, over the counter etc.
0/300
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