Form Preview PDP Shopping Questionnaire PDP Shopping Questionnaire Please complete form if you would like HTA to review your Prescription Drug Coverage for plan year 2022. *Prescription Drug Plans can only be shopped between October 15th and December 7th annually. PLEASE NOTE, WE CAN ONLY ACCEPT REQUESTS UNTIL SUNDAY 11/28/2021 to allow enough time for analysis prior to the 12/7/2021 enrollment deadline. **Due to high call volumes this time of year, Prescription Drug Plan/Medicare Advantage Plan Shopping is only available to existing clients who are already enrolled through HTA in a Medicare Supplement/Medicare Advantage or Medicare Prescription Plan. PLEASE COMPLETE A SEPARATE FORM FOR EACH SPOUSE. 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 2021, 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