Instructions

Do NOT include Vitamins, Supplements, or OTC drugs since these are not covered by Part D. Please ONLY list Prescribed Medications in the form.

If you have an upcoming doctor’s appointment (e.g. in October/November) that could impact your Rx list, please put a Note in the ‘Additional Drugs/Info’ field.

Also do NOT include diabetic supplies (e.g. test strips, needles, etc.) since these are covered by Part B of Medicare under Durable Medical Equipment not under Part D of Medicare. The exception to this rule is the Omnipod “pods” since these are covered under Part D (not Part B).

If you are not taking any medications, complete the fields below and select “No” for “Do you currently take any medication?”, skip the Drug Info fields, and click Submit.

If you are taking prescribed medications that are NOT pill form (e.g. Insulin, Eye Drops, Creams, Lotions, Inhalers), in the “times per day” field below please just enter the amount per month that you fill (e.g. 5 pens per month, 1 bottle per month, 1 inhaler per month, etc.)

If your drug is “as needed” or “PRN” please put an estimate in the “times per day” fields below (e.g. refill inhaler twice per year).

The Part D Rx form is for one individual. Do not submit information for multiple people on the same form. For example, a husband and wife need to submit one form each with their individual information.