Getting Ready for the Annual Open Enrollment Period for Californians over 65 years. by Barbara Kempen | Sep 29, 2014 | Uncategorized ANNUAL ENROLLMENT PERIOD MEDICARE REVIEW SHEET( OCT15- DEC 7 TH) Please circle your choices Drug Name or None Circle one Dosage per day Generic / Name Brand Generic / Name Brand Generic / Name Brand Generic / Name Brand Generic / Name Brand Generic / Name Brand Generic / Name Brand Current Medicare Plan Insurance Carrier Plan Name Medicare Supplemental orMedicare Advantage Current PremiumSatisfied or not ? $ ____________ per monthYes /No Month enrolled Current Part D – RX- PrescriptionPlan Current PremiumSatisfied or not $ ____________ per monthYes /No Preferred Pharmacy: City Please circle the one’s you are intersted in reviewing or need: Medicare Supplemenal Plan MedicareAdvantage Plan Part D Plan Dental /VisionPlan Travel Insurance Life Insurance Plan Long Term Care Final Expense Plan Name: Email: Address: Phone:Date Of Birth: Click here to download as PDF
