Part D Simplified

Caution you are entering the AEP Zone

Annual Enrollment Period begins October 15th to December 7th, 2011.
This is how My Medicare Planner navigates the Medicare Part D Maze for you.

Every year plans change and the very drug that is covered this year may not be covered in 2011. Or, it could be moved to a higher tier. To insure that you get the best drug plan we run Medicare’s Prescription Drug Plan Finder for you at no additional cost to you. Savings & Service you can’t pass up!

Now is the time to evaluate your plan. Just fill out the form below and you may enter the Peace of Mind Zone.

Start saving hundreds on your current prescription medications.

Sign up for Part D coverage today!

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Medicare Beneficiary

Please provide the following information as it appears on your Medicare card.

Title* First Name* Middle Initial* Last Name*

Date of Birthday

Date*

Your Contact Information

Street Address* City or County*

State* Zip Code*

Phone* - - Email*

Contact Person

Complete if different from Beneficiary above.

Title* First Name* Middle Initial* Last Name*

Street Address* City or County*

State* Zip Code*

Phone* - - Email*

Maintenance Medications

Copy prescription drug information from the Rx bottle to insure accuracy. Include drug name, dosage and frequency for each medication. If the drug you are taking is a generic medication list the generic drug name.

Drug #* Doseage* Refil Quantity* Frequency* Add Another Drug

Special Drug Instructions

Add Spouse

Spouse Date of Birthday

Date*

Spouse Contact Information

Street Address* City or County*

State* Zip Code*

Phone* - - Email*

Maintenance Medications

Drug #* Doseage* Refil Quantity* Frequency* Add Another Drug