Medicare Prescription Drug List
Please enter your information and prescriptions below:
Street Address Line 2
State / Province
Postal / Zip Code
Other convenient pharmacies
You may upload an image of your drug list here or enter medications below.
List any additional medications or (Physician Names here for Advantage Plans Only)
If you need help affording any medicines please enter the names here.
Would you like help applying for a low income subsidy, medicaid or pharmaceutical assistance based on financial need?
I acknowledge that I have received a copy of DMIA Privacy Notice located at dougmcculloughinsuranceagency.com/privacy. I also agree to be contacted about prescription drug coverage. E-Signature (Type Name below)
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