Annual Medicare Review Form | Arch Brokerage

PHYSICIANS

Primary Care

Address

Specialist

Type of Specialist

Name

First Last

Address

Specialist 2

Type of Specialist

Name

First Last

Address

Specialist 3

Type of Specialist

Name

First Last

Address

Specialist 4

Type of Specialist

Name

First Last

Address

Hospital Preference

Prescription Drug(s) Currently Prescribed

Pharmacy Preference

Switch Pharmacies to Save?

Yes

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

This form defaults to five prescriptions and will auto-populate additional prescription fields as needed.

1. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

2. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

3. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

4. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

5. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

6. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

7. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

8. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

9. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

10. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

11. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

12. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

13. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

14. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

15. Drug Name

Dosage

Package

Other Package

Package Size

Quantity Per Refill

Refill Frequency

How often do you refill this medication?

Is Generic okay (Yes/No)?

Yes

Additional Information

If you are not currently on a Medicare Advantage plan (MAPD), would you be interested in having our team discussion options with you? Type yes or no.

Form Completion*

I confirm that the information provided is accurate to the best of my knowledge.

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.

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Client

PHYSICIANS

Specialist

Specialist 2

Specialist 3

Specialist 4

Prescription Drug(s) Currently Prescribed

Instructions And Examples