Prescription Drug Plan Worksheet Get in Touch With A-1 Insurance Group, Inc. Enter your medications here: Do you take a medication?*NoYesMedication Name* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 1* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 2* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 3* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 4* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 5* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 6* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 7* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 8* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 9* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 10* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 11* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 12* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 13* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 14* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 15* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 16* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 17* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 18* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 19* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 20* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 21* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 22* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 23* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 24* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 25* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 26* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 27* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 28* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 29* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 30* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 31* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 32* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 33* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 34* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 35* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 36* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 37* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 38* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 39* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Add another medication*YesNoMedication Name 40* Quantity*Per*DailyWeeklyMonthlyEvery Three MonthsEvery Six MonthsOnce a YearType*TabletsCapsulesCannisterTubesBottlesVialspatchesDosage Type*MGMCGUnits Per Day% SOLUTIONDosage Amount* Name of your Preferred Pharmacy:* Pharmacy local pick up or mail order* Medicare Number (FOR EXISTING CLIENTS ONLY)Part A effective date MM slash DD slash YYYY (FOR EXISTING CLIENTS ONLY)Part B effective date MM slash DD slash YYYY (FOR EXISTING CLIENTS ONLY)Name First Last Email* Phone*DOB* Month Day Year Address* Apt number/unit City State Zip County* Upload your files hereMax. file size: 100 MB.Comments or QuestionsPhoneThis field is for validation purposes and should be left unchanged.
