The Annual Open Enrollment Period starts October 15 th for Californians over 65 years old

The Annual Open Enrollment starts October 15th and ends December 7th. In this period Medicare eligible Americans should review their Medicare Advantage and Prescription Plans to see if the plans of 2015 still fits their needs. Please reevaluate if you are taken any new prescription drugs of if possible your existing Medicare Advantage Plan is leaving your service area.

Here is a quick check list which will help you to make the review process easier .

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 or Medicare Advantage
Current Premium Satisfied or not ?	$ ____________ per month Yes /No	Month enrolled
Current Part D – RX- PrescriptionPlan
Current Premium Satisfied or not	$ ____________ per month Yes /No
Preferred Pharmacy:		City

Please circle the one’s you are intersted in reviewing or need:

Medicare Supplemenal Plan

Medicare

Advantage Plan

Part D Plan

Dental /VisionPlan

Travel Insurance

Life Insurance Plan

Long Term Care

Final Expense Plan

Name:_____________________________________________________

Email:

Address:

Phone:

Date Of Birth:___________________________________________

In case you are taken more than 7 medication please add the list

Continued Medication List

Drug Name	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

Any other concerns or need I should know about :

_____________________________________________________________________________________________________