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Medicare Fact Finder – Client
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About
Contact
Employee Benefit Plans
Employee Benefit Plans Overview
Group Health Plans
Life Benefits
Dental Benefits
Vision Benefits
Accidental Death
Long Term Care Insurance (LTC)
Disability Benefits
Medicare
Medicare Overview
Medicare Supplements
Medicare Advantage Plans
Prescription Drug Plan
Life Insurance
Annuities
Long Term Care Insurance (LTC)
Dental Benefits
Vision Benefits
Travel Policies
Individual Coverage
Individual Coverage Overview
Health Insurance
Life Insurance
Annuities
Long Term Care Insurance (LTC)
Dental Benefits
Vision Benefits
Travel Policies
Forms
Medicare Fact Finder – Client
Individual Fact Finder
Prescription Drug Fact Finder
About
Contact
Client Name
*
Please enter one entry for each spouse
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
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New Hampshire
New Jersey
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New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Prescription Drug(s) Currently Prescribed
Substitute Generics for Brand?
Yes
No
Preferred Pharmacy
Current Prescription Drug Plan Name
Switch Pharmacies to Save?
Yes
No
1. Name of Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank. Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
2. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
3. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
4. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
5. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
6. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
7. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
8. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
as needed
9. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
10. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
11. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
12. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
13. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
14. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
15. Name of Drug
Dosage
Mg or ML
Frequency
1 x per day
2 x per day
3 x per day
weekly
as needed
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
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