Medicare Advantage Plan Analysis

SAFE • SECURE • EASY • CONFIDENTIAL
Section 1 - Applicant Information
Section 1 - Applicant B Information
Have you lived in the same household as someone 60 years old or older for the past 12 months?
Section 2 - MEDICATION INFORMATION.
 

Applicant A

Medication Name
(Please enter exact name from prescription label)
Have you taken this medication for more than 2 years?
Prescribed by Primary Physician?
Dosage
Frequency
Diagnosis / Condition
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No

Applicant B

Medication Name
(Please enter exact name from prescription label)
Have you taken this medication for more than 2 years?
Prescribed by Primary Physician?
Dosage
Frequency
Diagnosis / Condition
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Section 3 - PREFERRED PHARMACIES AND PROVIDERS.
 

Applicant A

Pharmacies Applicant A
Pharmacy Name:
Address:
City:
State: Zip:
Pharmacy Name:
Address:
City:
State: Zip:
Provider Applicant A
Primary Care Physician:
Address:
City:
State: Zip:
Hospital Name:
Address:
City:
State: Zip:
Specialist #1:
Address:
City:
State: Zip:
Specialist #2:
Address:
City:
State: Zip:
Specialist #3:
Address:
City:
State: Zip:

Applicant B

Pharmacies Applicant B
Pharmacy Name:
Address:
City:
State: Zip:
Pharmacy Name:
Address:
City:
State: Zip:
Provider Applicant B
Primary Care Physician:
Address:
City:
State: Zip:
Hospital Name:
Address:
City:
State: Zip:
Specialist #1:
Address:
City:
State: Zip:
Specialist #2:
Address:
City:
State: Zip:
Specialist #3:
Address:
City:
State: Zip:

If you have any questions or need help completing this form, please contact us at 800-290-7535.

*Required Information