Medication List

Please provide an updated, accurate and complete list of all the medications you take on a regular basis.

*Results are determined by information obtained directly from the Medicare database.

Please be sure to check the accuracy of the information provided, to get the best and most accurate RX plan.

Name *

First

Middle

Last

Current Plan Name *

Current Plan Type *

Prescription Plan
Medicare Advantage

Email *

Confirm Email

Phone *

Medications

Be sure to include all prescription medications, with dosage and quantity.

[1] Medication Name

[1] Dosage Amount

[1] # Taken Daily

[2] Medication Name

[2] Dosage Amount

[2] # Taken Daily

[3] Medication Name

[3] Dosage Amount

[3] # Taken Daily

[4] Medication Name

[4] Dosage Amount

[4] # Taken Daily

[5] Medication Name

[5] Dosage Amount

[5] # Taken Daily

[6] Medication Name

[6] Dosage Amount

[6] # Taken Daily

[7] Medication Name

[7] Dosage Amount

[7] # Taken Daily

[8] Medication Name

[8] Dosage Amount

[8] # Taken Daily

[9] Medication Name

[9] Dosage Amount

[9] # Taken Daily

[10] Medication Name

[10] Dosage Amount

[10] # Taken Daily

[11] Medication Name

[11] Dosage Amount

[11] # Taken Daily

[12] Medication Name

[12] Dosage Amount

[12] # Taken Daily

[13] Medication Name

[13] Dosage Amount

[13] # Taken Daily

[14] Medication Name

[14] Dosage Amount

[14] # Taken Daily

[15] Medication Name

[15] Dosage Amount

[15] # Taken Daily

[16] Medication Name

[16] Dosage Amount

[16] # Taken Daily

[17] Medication Name

[17] Dosage Amount

[17] # Taken Daily

[18] Medication Name

[18] Dosage Amount

[18] # Taken Daily

[19] Medication Name

[19] Dosage Amount

[19] # Taken Daily

[20] Medication Name

[20] Dosage Amount

[20] # Taken Daily

[21] Medication Name

[21] Dosage Amount

[21] # Taken Daily

[22] Medication Name

[22] Dosage Amount

[22] # Taken Daily

[23] Medication Name

[23] Dosage Amount

[23] # Taken Daily

[24] Medication Name

[24] Dosage Amount

[24] # Taken Daily

[25] Medication Name

[25] Dosage Amount

[25] # Taken Daily

Pharmacy Name *

Today's Date *