347 N. Pottstown Pike, Suite 200 | Exton, PA 19341

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AEP Shopping Questionnaire 2022
Do you want to provide info for spouse/partner?

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)?
Do you want to shop YOUR SPOUSE'S/PARTNER'S Prescription Plan (recommended)?
Would YOU like to receive a text message with YOUR plan information (in addition to an email)?
YOUR Change Preference
YOUR Shopping Location Preference (choose 1 or both)

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.

Would you like to receive a text message with your plan information (in addition to an email)?
Change Preference
Shopping Location Preference (choose 1 or both)

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.

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?
Do you want to shop YOUR SPOUSE'S/PARTNER'S Medicare Supplement Plan?
Change Preference (check all that apply)
Frequency
Did you receive a notice that your premiums are going up?

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.* *

Congestive Heart Failure *
Diabetes With History of Heart Attack or Stroke *
Internal Cancer or Melanoma *
Diabetes With Complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease) *
Kidney or Liver Disease *
Atrial Fibrillation, TIA or Stroke *
Diabetes With Insulin Use *
Osteoporosis With Fractures *
Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis
Are you currently receiving Physical Therapy? *
Do you have any scheduled surgery or treatment in the next 12 months? *

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.

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)
Do you have interest in any other types of benefits?
If applicable-Would you like us to shop for your spouse/partner also?
I understand HTA will email me my plan results on a first come first serve basis after 10/15.