Medicare Part D Plan Evaluation

1
Name
First Name
Last Name
2
Date Of Birth
Date
Year
Month
Day
3
Email
example@example.com
4
Phone Number
Please enter a valid phone number.
5
What plan did you have in 2022? (be as specific as possible)Aetna PDP, SilverScript Choice...etc,..
6
Please list all of your everyday or frequently filled prescriptions. Please include anything you would fill more than 2 times in a year. This should include all blood pressure, asthma, diabetes, etc...medications - But not one time pain medications or antibiotics unless you take them prophylactically.
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7
How do you want to be provided this document?
I will pick it up at the pharmacy in 3-4 days
I would like it emailed to me to review (at the email provided earlier)
8
Please Read and Sign Below I agree to have my health information contained in this form be included in an email if I selected that in previous question. I understand that this is only a projection of my potential costs and that Vashon Pharmacy is not liable for any changes to plan costs, formularies or changes in healthcare not provided specifically within this form. I understand that Vashon Pharmacy is only providing information regarding my prescription drugs and not considering my medical conditions and/or insurance in any way in this equation. I agree to hold Vashon Pharmacy, its employees and affiliates harmless in any and all matters related to my selection of a Medicare Prescription Drug Plan.
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