Drug List - Siouxland Medicare Planning

Prescription Drug

Plan Review

Submit your Drug List

Used for Part D (Prescription Drug Plan) and for Part C (Medicare Advantage Plans)

First Name & Last Initial *

First

Last

Phone Number

Email Address *

Primary Pharmacy

Secondary Pharmacy

If your secondary pharmacy was projected to lower your out of pocket drug costs, how much money would it need to save you before you may consider changing?

$50 Projected Annual Savings
$250 Projected Annual Savings
$500 Projected Annual Savings
I don't Want to Consider Changing Pharmacy for any Potentional Savings

Drug plan pharmacy networks do vary. I will always first look for the plans that best fit your preferred pharmacy.

Current Drug Plan Name

Optional Drug List Upload (Remove all Personal Information)

Drag & Drop Files, Choose Files to Upload

You are welcome to upload your list here instead of completing the below form.

I Don't Regularly Take Prescription Drugs

Check this box if the statement applies to you.

Drug 1

First

Middle

Last

Drug #2

First

Middle

Last

Drug #3

First

Middle

Last

Drug #4

First

Middle

Last

Drug #5

First

Middle

Last

Drug #6

First

Middle

Last

Drug #7

First

Middle

Last

Drug #8

First

Middle

Last

Drug #9

First

Middle

Last

Drug #10

First

Middle

Last

Use This Space to Enter Additional Drug Information

Additional Comments

Disclaimer: Siouxland Medicare Planning is a local independent insurance agency with a focus on Medicare planning and serving local clients. Not connected with or endorsed by the United States government or the federal Medicare program. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-Medicare or SHIP to get information on all your options.