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: |
