Medication Form

This form is SECURE. Information you provide will be encrypted.
This form is HIPAA compliant.

Full Name

Zip Code

County

not country :)

Date of Birth

Please provide accurate information. Please enter the brand name when taking the brand Rx and generic when taking the generic.

Unfortunately, we cannot guess if a medication should have been entered differently. For example: if you enter the Brand Name "Synthroid," we can't guess if it should have been the generic "Levothyroxine."

If you enter a brand, we'll make recommendations off providing good coverage for the brand - and the insurance may cost more than it should have if we factored in getting coverage for lower-cost generics.

I understand and agree

Yes - I will look at the bottles and I will be thorough so that Scott can properly help and give better advice. (Please take the extra few minutes and complete this correctly so that we can provide accurate advice).

The next section is for medication which comes in common forms (i.e. Tablets/Capsules).

Note: some medications may not "fit" below (for example, insulin). We have a separate section below for those types of medications that aren't tablets/capsules.

Please do not enter OTC - i.e. vitamins, baby aspirin

I understand that I do not need to include OTC and Vitamins

NOTE: You can enter up to 15 medications - simply click "add new row" to enter another medication.

Add new row

Reminder: You can enter up to 15 medications - simply click "add new row" to enter another medication.

You can use this section for Medications which don't fit - i.e., let's say you take insulin, and you use about one Insulin Pen every 10 days, or 3 pens monthly. But you get a 90-day supply of 9 pens. In this section, simply indicate those details and describe it to the best of your ability.

Enter medications that don't fit above or medications that need further details.

Are any of the medications above "Part B" medications, rather than "Part D"? A medication is typically "Part D" if you fill it at the pharmacy and self-administer. A medication may be covered under "Part B" if it is an medication administered by a provider - like a shot for bone density, or a shot for macular degeneration.

As far as I know, everything I've listed is regular medication, filled at the pharmacy. I think I entered at least one medication above that is a "Part B" medication since it's more of a treatment and a provider administers it.

Which medication do you think is likely covered under Part B?

For any of the medications above, do you get "Patient Assistance?" i.e., maybe the drug manufacturer covers the cost of Ozempic for you. If yes - please enter that information below.

Yes, I get Patient Assistance on Prescriptions I don't get any assistance other than insurance

What medication to get you assistance on, and will that continue for you? Please provide details below for me.

Because you are getting Patient Assistance for the above listed medication, do you still need/want insurance coverage for it?

Yes, just to be safe. I may not need my insurance for this medication, but I want it as a "fallback" No, I don't think so. The manufacturer is covering my costs and I'm confident that they'll continue to do so. I do not want to make sure my insurance program has this medication on their list of covered drugs.

Do you use discount programs - like GoodRx, our any of the other free cards that come in the mail?

No, I usually just use my insurance. Yes, I use a discount card on specific prescriptions

Discount Program Details - please indicate which Rx's you use discount programs for (i.e., "GoodRx for Tamsulosin") and the estimated price you've been paying (note: we don't guarantee that GoodRx and/or other discount programs will continue to provide discounts - although they seem to work well).

Because you are a discount program, rather than insurance for some/all of the above listed medication(s), do you still need/want insurance coverage for those Rx's?

Yes, just to be safe. I may not need my insurance for this medication, but I want it as a "backup" No, I don't think so. I'm going to rely on the discount program(s).

Which Pharmacy (or pharmacies) do you currently use?

Are you open to changing pharmacies if the savings is significant? If yes, let us know some more details: For example, "I'm open to any pharmacy" OR "I'm open to changing but would prefer not to" OR "I'm open to changing to ___, but not ___"

We won't check every single pharmacy but we often check a few alternatives.

Are you open to using Mail Order?

Yes No

Do we have your permission to communicate some details about your insurance plan(s) electronically (text/email), as outlined in our Electronics Communication Policy (startmedicareright.com/elec-comm-policy)? A common example is communication regarding specific medication tier levels.

Yes No

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Medication Form

Medication Intake Form

Medication Intake Form

Scott Shafran

StartMedicareRight.com