PART D - Prescription Drug Form

By completing this form on our secure server, it will save us both time from gathering the spelling of each drug over the phone. Once we receive your form, a member from our team will contact with you regarding your Part D options and recommend a plan that fits your needs and budget.

*** IMPORTANT ***

Please provide the following information for each drug:

1) Correct Spelling of the Drug

2) Quantity (Frequency)

3) mg Strength (Dosage)

4) Diagnosis (what it treats)

5) "B" = Brand / "G" = Generic