Part D Questions General InformationName *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *County (NOT Country) *Phone *Email Address *Date of Birth *Gender (Assigned at Birth) *MaleFemaleMedicare Number *Ex: 2HH7-HH6-GH00Part A Effective Date *Part B Effective Date *Current Prescription PlanSelect Your Current Part D Plan *SelectAARP Medicare Rx Preferred from UHCAARP Medicare Rx Saver from UHCAetna SilverScript ChoiceCigna Healthcare Assurance RxCigna Healthcare Extra RxCigna Healthcare Saver RxHighmark Blue Rx CompleteHighmark Blue Rx PlusHumana Basic RxHumana Premier RxHumana Value RxWellcare ClassicWellcare Medicare Rx Value PlusWellcare Value ScriptOtherPlease Enter Your Plan Name *Pharmacy InformationPharmacy Name *Street Address *City *State/Province *ZIP / Postal Code *Prescription InformationOnly include what you get at the pharmacyMedicationMedication Name *Please type N/A If you do not take medicationsDose *Please type N/A If you do not take medicationsForm *Select N/A if this doesn't applySelectTabletCapsuleSprayGelCreamOintmentPatchInjectionBottleInhalerN/AQuantityRefill Quantity (Type "0" if this doesn't apply)Refill FrequencyChoose N/A if this doesn't applySelect30 Days60 Days90 Days6 Months1 YearN/ASubsidy InformationDo you receive extra help paying for prescription drugs? *SelectI receive help from MedicaidSupplemental Security IncomeMedicare Savings ProgramExtra Help from Social SecurityI don’t get help from any of these programsSubmit
