MyInfo

Do you already have a MyMedicare account? Please note, this is a requirement again this year for all participants to get a review recommendation. Yes No

Medication List:

Please provide the information directly off of your prescription bottle. You will need to include: Medication name, dosage, how many you take per day, refill frequency, and specify the medication type.

We need accurate and complete information so we can find you the lowest cost prescription drug coverage. Making sure your medication is generic vs. brand name as well as telling us if it is a tablet vs. a capsule or an injection vs. a kit is essential because this can change the drug costs significantly.

Input each of your medications in the separate boxes below one by one.

For example:
Ezetimibe, 10mg, 1 tablet daily, 1 month refill frequency
Doxycyline Hyclate, 100mg, get 90 capsules, 3 month refill frequency
Sildenafil, 20mg tablets, bottle has 12 tablets and take as needed, refill every 3 months
Humalog Kwikpen, injections- get 5 pens at a time, refill frequency 1 month

PLEASE NOTE: We do not need your over-the-counter medications listed here. Over-the-counter medications will not be covered by Medicare.

!! IMPORTANT !! It is critical that we know if you take a BRAND NAME or GENERIC form of your medication, as there can be thousands of dollars in cost differences. Providing incorrect medication information will result in you over-paying for your medications.

Medication #1: (Information located directly on your prescription bottle)

Medication Name^*

Medication Type^*

Dosage^*

Daily Amount or Refill Quantity Received^*

Refill Frequency^*

Enter Comments About Your Medications, if Applicable (This is a good place to tell us if you take generics of any medications or further information on dosing or refill frequency that you were not able to input above)

Request for Prescription Information

Medication List:

Medication #1: (Information located directly on your prescription bottle)