Prescription Drug Form

Please Enter Your Contact Information

First Name * Last Name * Email Address * Address * City *

State *

Zip * Phone Number * Current Policy Current Premium Agent Name

Do you receive "Extra Help" from Social Security or Medicaid? *noyes

Please Enter Your Medicaid Number

Do you live at a different address between October 15th and December 7th? * noyes

If yes, please provide the address here *:

Do you use insulin or injections? *: noyes

Name of Insulin *: Pen Size : Mix/Concentration : Number in Package : Number Used Per Month :

Do you use an Inhaler or Nebulizer? *: noyes

Name of Inhaler or Nebulizer *: Size (GM/ML) *: Number Used Per Month *:

Do you use medicated creams, gels, ointments, lotions or shampoos? *: noyes

Product name *: Product Type *: Concentration *: Refill Quantity per month/year *:

Do you take medication? *: noyes

Drug Name *: Name Brand or Generic *: Dosage *: Type *: How Many Per Day *: How Often Do You Refill

What Are Your Preferred pharmacies:

If prices are cheaper at another pharmacy in my area, I will change pharmacies: * yesno

1-810-225-0464

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