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PDP Shopping Questionnaire 2021
Name (Full name as it appears on your Medicare Card)
*
Date of Birth
*
Phone Number
*
Street Address
*
City
*
State of Residence
*
County of Residence
*
Zipcode
*
Email
*
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
Please indicate if there are any other products you would like to discuss (in addition to Prescription)
Medicare Supplement
Medicare Advantage (instead of Medicare Supplement and Standalone Prescription Plan)
Dental Coverage
Vision Coverage
Hearing Aid Coverage
Home Health Care and or Nursing Home Coverage
If you are human, leave this field blank.
Submit
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