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Getting Ready for the Annual Open Enrollment Period for Californians over 65 years.

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:

 

Click here to download as PDF

 

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