What County Are You In
Your Zip Code
Who is your agent?
Please fill in the sheet below with all of your current prescription medications. This will assist us in helping you shop for your Prescription Drug Coverage.
What is Your Preferred Pharmacy?
Are you willing to go to another pharmacy if needed to lower your prescription costs?
What is Your Preferred Hospital?
RX Drug Search
Dosage (MG Amount)
Times Per Day
Generic or Brand?
Questions, comments additional medications
By completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare Supplement plans. This is a solicitation for insurance.