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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 :

_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

 

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