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 QuestionsCommentsThis field is for validation purposes and should be left unchanged.
