Medications / PDP Quote

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Please provide your answers in the field below the question. When finished, scroll to the bottom and hit the submit button. Please do not include over the counter vitamins or medications.

For each medication, please provide the following information as detailed below:
1. Name: Lisinopril or Lisinopril/HCTZ
2. Dosage: 10, 20 or 40 MG / Tab, Capsule, Inhaler, Drop etc
3. Frequency: 1 x Daily, 2 x Daily, 3 x Daily, other
4. Do you use a 90 day mail order?
4. Optional: Additional details regarding unique medication use?

Name *

Email (need somewhere to send quote). Quote will be sent in two emails. The first email is a code you need to open the second one. *

Birthdate *

YYYY

Zip Code *

County of Residence (not country) *

Part A & B Effective Dates (if unknown, leave blank)

Pharmacy Preference *

Retail (Walgreens, CVS, Grocery Store)

Mail Order

Both

Medications

Please do not include vitamins or over the counter medications such as Advil, Allergy Medicines, etc. Also, please be very specific on your medications as outlined at the top of the form. Complete name, dosage type (tab/capsule/solution/mg/mcg ) & frequency.

Med 1:

Med 2:

Med 3:

Med 4:

Med 5:

If you have more than 5 medications please list the rest in this space below using same criteria.

How did you hear about us? Any additional info you think would help, please list. *

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