Schedule AEP Shopping Questionnaire 2022 First Name (listed on Medicare Card) * Last Name Date of Birth * Email * Do you want to provide info for spouse/partner? Yes No Spouse/Partner First Name (listed on Medicare Card) * Spouse/Partner Last Name * Date of Birth * Email * Phone Number * Street Address * City * State of Residence * County of Residence * Zipcode * Prescription Drug Plans can only be shopped between 10/15 and 12/7 each year. It is highly recommended that we confirm your current prescription list to make sure that there are no drastic changes in coverage next year. Do you want to shop YOUR Prescription Plan (recommended)? Yes No Do you want to shop YOUR SPOUSE'S/PARTNER'S Prescription Plan (recommended)? Yes No Would YOU like to receive a text message with YOUR plan information (in addition to an email)? * Yes No Cell Number * YOUR Change Preference * I am satisfied with my current plan. Assuming coverage is similar to this year, I would like to keep it. I have been dissatisfied and prefer to change plans. Please provide details as to what you don't like about your current plan so we may see if there is something that would be a better fit. YOUR Shopping Location Preference (choose 1 or both) * Visit a Retail Pharmacy Store Mail Order 1st Choice-Name of Pharmacy * 2nd Choice-Name of Pharmacy Finding the most appropriate Prescription Drug Plan requires us to have a list of your current medications. Please provide a list of your current medications, including any "as needed" medications that you expect to fill in 2022. *Please exclude any OTC meds or vitamins you may take. How many Medications do YOU take (if over 8, please contact HTA to schedule a phone appointment). * 0 1 2 3 4 5 6 7 8 Medication 1 (as listed on your Rx bottle) * Dosage and Frequency (ex: 20mg, 2/day) * Brand Required? * No Yes Medication 2 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 3 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 4 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 5 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 6 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 7 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 8 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Would you like to receive a text message with your plan information (in addition to an email)? * Yes No Cell Number * Change Preference I am satisfied with my current plan and assuming that my pharmacy and medications are covered similarly to this year, I would like to keep my plan I prefer to change plans because I have been dissatisfied Please provide details as to what you don't like about your current plan so we may see if there is something that would be a better fit. Name of your Prescription Plan (exactly as it appears on your ID Card) * Shopping Location Preference (choose 1 or both) * Visit a Retail Pharmacy Store Mail Order 1st Choice-Name of Pharmacy * 2nd Choice-Name of Pharmacy Finding the most appropriate Prescription Drug Plan requires us to have a list of your current medications. Please provide a list of your current medications, including any "as needed" medications that you expect to fill in 2022. *Please exclude any OTC meds or vitamins you may take. Number of Medications (if over 8, please contact HTA to schedule a phone appointment) * 0 1 2 3 4 5 6 7 8 Medication 1 (as listed on your Rx bottle) * Dosage and Frequency (ex: 20mg, 2/day) * Brand Required? * No Yes Medication 2 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 3 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 4 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 5 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 6 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 7 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medication 8 (as listed on your Rx bottle) * Dosage and Frequency * Brand Required? * No Yes Medicare Supplement Plans can be shopped any time during the year, but generally are medically underwritten if you have been enrolled in Medicare longer than 6 months (state exceptions apply). There are NO benefit changes on January 1st. Generally premiums change on your annual policy anniversary date which may not be January 1st. If you purchased or shopped your plan in the past 3 years, it is likely that your current plan remains very competitive unless you have gotten a large rate increase since the last time we spoke. Do you want to shop YOUR Medicare Supplement Plan? * Yes No Do you want to shop YOUR SPOUSE'S/PARTNER'S Medicare Supplement Plan? * Yes No Current Plan * Plan G Plan F Plan N Plan High Deductible G (or F) Other Unsure Change Preference (check all that apply) * I want to see if there is a lower rate for the same benefits I have now I would be willing to look at a higher out of pocket risk to save money on premium Current Plan Premium * Frequency * Monthly Quarterly SemiAnnual Annual Did you receive a notice that your premiums are going up? * Yes No Date of Rate Increase * New Premium after Increase * Shopping Medicare Supplement plans requires medical underwriting, please indicate if you have been diagnosed or treated with any of the following health conditions in the last five years: *Answering the health questions below allows us to determine which insurance company may be the most appropriate based on your health history.* * Tobacco Use * Choose Option Yes No Congestive Heart Failure * Yes No Details Diabetes With History of Heart Attack or Stroke * Yes No Details Internal Cancer or Melanoma * Yes No Details Diabetes With Complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease) * Yes No Details Kidney or Liver Disease * Yes No Details Atrial Fibrillation, TIA or Stroke * Yes No Details Diabetes With Insulin Use * Yes No Details Osteoporosis With Fractures * Yes No Details Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis * Yes No Details Are you currently receiving Physical Therapy? * Yes No Details Do you have any scheduled surgery or treatment in the next 12 months? * Yes No Details Medicare Advantage Prescription Drug (MAPD) Plans are an all-in-one alternative to a Medicare Supplement and Standalone Prescription Drug Plan. MAPD Plans are network based plans. You can only enroll in MA between 10/15 and 12/7 each year. If you would like to look into MA, please be sure to watch the video on our AEP Planning Page. AEP Planning Webpage Do you want to shop a Medicare Advantage Plan? (If so, we will ask you to provide information on your desired doctors so we can confirm networks) Yes No Please provide details as to why you are interested in Medicare Advatange 1st Choice-Hospital Name * Location-City, State * 2nd Choice-Hospital Name Location-City, State Number of Doctors you currently see (if over 8, please contact HTA to schedule a phone appointment) * 0 1 2 3 4 5 6 7 8 Doctor 1 (Primary) * Willing to change providers? * No Yes Address * City * State * Zip * Doctor 2 * Specialty * Willing to change providers? * No Yes Address * City * State * Zip * Doctor 3 * Specialty * Willing to change providers? * No Yes Address * City * State * Zip * Doctor 4 * Specialty * Willing to change provders? * No Yes Address * City * State * Zip * Doctor 5 * Specialty * Willing to change providers? * No Yes Address * City * State * Zip * Doctor 6 * Specialty * Willing to change providers? * No Yes Address * City * State * Zip * Doctor 7 * Specialty * Willing to change providers? * No Yes Address * City * State * Zip * Doctor 8 * Specialty * Willing to change providers? * No Yes Address * City * State * Zip * Do you have interest in any other types of benefits? Dental Coverage Vision Coverage Home Health Care and or Nursing Home Coverage Gym Membership Discounts Dentist Name * Location- City, State, Zip * Willing to change providers? * No Yes If applicable-Would you like us to shop for your spouse/partner also? * Yes-I will provide their details below Yes-I will have them provide their forms separately No Thank You I understand HTA will email me my plan results on a first come first serve basis after 10/15. * I agree If you are human, leave this field blank. Submit