Prescription Drug Fact Finder | Arch Brokerage

Client Name*

Please enter one entry for each spouse

First Last

Date of Birth

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Please select below the type of product(s) you want the agent to discuss.

Stand-alone Medicare Prescription Drug Plans (Part D)

Yes

Medicare Advantage Plans (Part C) and Cost Plans

Yes

Dental/Vision/Hearing Products

Yes

Supplemental Health Products

Yes

Medicare Supplement (Medigap) Products

Yes

Prescription Drug(s) Currently Prescribed

Preferred Pharmacy

Switch Pharmacies to Save?

Yes

Current Drug Plan Name

Instructions And Examples

✔ DO NOT list over the counter (OTC) vitamins, supplements, and/or prescriptions not purchased under Part D.

✔ DO NOT state "as needed." Instead, provide an estimate based on the frequency you use this drug.

✔ For inhalers, eye drops, creams, lotions, or ointments, provide size of bottle/tube and frequency of refills.

✔ For insulin or injectables provide units per day or pens per month.

Drug Name	Dosage (mg/mcg/ml/gm)	Package (capsule, tablet, vial, inhaler, pen, etc)	Quantity	Refill Frequency (How often do you refill this medication?)	Is Generic OK? (Yes/No)
Drug Name	Dosage (mg/mcg/ml/gm)	Package (capsule, tablet, vial, inhaler, pen, etc)	Quantity	Triamterene-HCTZ	37.5-25 mg	capsule	90	Every 3 months	Yes
Simvastatin	10 mg	tablet	90	Every 3 months	Yes
Fluticasone Propionate	50 mcg	16 gm bottle	3	Every 12 Months	Yes
Albuterol	90 mcg	18 gm inhaler	1	Every 6 months	Yes
Triamcinolone Acetonide	0.1%	15 gm tube	1	Every 2 months	Yes
Humalog	100 unit/ml	pen	5	Monthly	No
Novolin R	100 unit/ml	vial	1	Monthly	No

1. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No)

Yes

2. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

3. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

4. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

5. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

6. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

7. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

8. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

9. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

10. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

11. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

12. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

13. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

14. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

15. Drug Name

Dosage

Package

Other Package

Package Size*

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Generic (Yes/No

Yes

Additional Information

By responding to this request, I understand that I am not required to provide any private, protected health information (PHI). This information is only for use by Arch Brokerage to help make an informed plan decision and will not be shared with any third party. I agree that an Arch Brokerage representative may contact me by telephone, e-mail or US mail to discuss Medicare Advantage Plans, Prescription Drug Plans and Medicare Supplement Insurance Plans.

CAPTCHA