Prescription Drug Fact Finder | Arch Brokerage | St. Louis, MO

Employee Benefit Plans
Medicare
Individual Coverage
Forms
About
Contact

Employee Benefit Plans
Medicare
Individual Coverage
Forms
About
Contact

"*" indicates required fields

Client Name*

Please enter one entry for each spouse

First Last

Date of Birth

MM slash DD slash YYYY

Email

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

No

Medicare Advantage Plans (Part C) and Cost Plans

Yes

No

Dental/Vision/Hearing Products

Yes

No

Supplemental Health Products

Yes

No

Medicare Supplement (Medigap) Products

Yes

No

Prescription Drug(s) Currently Prescribed

Substitute Generics for Brand?

Yes

No

Preferred Pharmacy

Switch Pharmacies to Save?

Yes

No

Current Prescription Drug Plan Name

If you are taking insulin, inhalers, creams, or lotions, please specify the number of pens, vials, inhalers, bottles, tubes, etc. taken per month or year. Please do not state "as needed" as we need an approximate quantity to provide an accurate review.

Form can accommodate up to 15 drugs and will automatically add additional drug lines if needed.

Please do not list any over-the-counter medications.

1. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

2. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

3. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

4. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

5. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

6. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

7. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

8. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

9. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

10. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

11. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

12. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

13. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

14. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

15. Name of Drug

Dosage (mg/ml)

Frequency (How often do you take this medication?)

Quantity

Hidden

Prescription Drug Information

Please click + icon to add more drugs. If you don’t know the dosage, such as “500” mg, you may leave it blank. Only include numbers in the Dosage field.

Name of Drug

Dosage (Mg or ML)

Frequency

Additional Information

CAPTCHA

PHONE

FAX

EMAIL

LOCATION

(314) 849-9292

[email protected]

8084 Watson Rd # 100,
St. Louis, MO 63119

Employee Benefit Plans Individual Coverage Medicare

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