The Annual Open Enrollment Period starts October 15 th for Californians over 65 years old by Barbara Kempen | Sep 30, 2014 | Affordable Health Insurance, Health Insurance Brentwood, Health Insurance Pacific Palisades, Health Insurance Santa Monica 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 : _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
