Prescription Drug Plan Analysis

SAFE • SECURE • EASY • CONFIDENTIAL
Section 1 - Applicant Information
Section 2 - Please list all prescriptions and over-the-counter medications you have taken in the past 24 months in the table below.
 

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
1) Pharmacy Name: Address:
2) Pharmacy Name: Address:
3) Pharmacy Name: Address:

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

*Required Information