AEP Review Questionnaire - Online Scheduling Phone Scheduling your Phone AppointmentSince you chose to have a Phone Appointment to review your options, you will be redirected to our scheduling page once the form is submitted. You will be able to view our schedules and choose a date and time that is convenient to you.First Name (as on Medicare ID Card)(Required) Last Name(Required) Email Address(Required) Phone Number(Required) Ok to text with Plan information (if available)(Required) Yes No Address(Required) City(Required) State(Required) Zip(Required) Would you like to also shop for a spouse/partner?(Required) Yes No Spouse/Partner InformationFirst Name (as on Medicare ID Card)(Required) Last Name(Required) Email Address(Required) Phone Number(Required) Ok to text with Plan information (if available)(Required) Yes No Prescription Drug PlanPrescription Drug Plans can only be shopped between 10/15 - 12/7 each year. We typically recommend that you do a quick review of your Prescription Drug Plan (PDP) every year even if you are happy with your plan. Prescriptions can be added and removed from the covered formulary list. Pharmacies can also go in and out of network each year. Would you like to shop a Prescription Drug Plan?(Required) Yes No Would you like to shop a Prescription Drug Plan for your spouse/partner?(Required) Yes No YOUR Prescription InfoFinding the most appropriate Prescription Drug Plan requires us to have a list of your current medications. Please provide a list of your current medications, including any "as needed" medications that you expect to fill in 2022. *Please exclude any OTC meds or vitamins you may take. ------ LIST NAME, DOSAGE AND QUANTITY EXACTLY AS IT APPEARS ON THE BOTTLE ------ IF BRAND IS REQUIRED, type the Rx name-Brand Required in the medication name field. Ex: Lipitor-Brand Required.Your Preference(Required) Prefer to keep my current Prescription Plan if my costs and coverages are similar next year Prefer to change plans because I have been dissatisfied Please provide any details of what you are looking for in a plan (or what you don't like about your current plan) so we can see if there is a more appropriate solution.(Required)Shopping Location Preference (choose 1 or both) *(Required) Retail Pharmacy Mail Order 1st Preference - Pharmacy Name(Required) 2nd Preference - Pharmacy Name YOU- Number of Prescriptions currently taking(Required)0123456789101112Medication 1 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 2 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 3 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 4 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 5 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 6 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 7 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 8 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 9 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 9 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 10 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 11 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 12 Name(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year SPOUSE/PARTNER'S Prescription InfoFinding the most appropriate Prescription Drug Plan requires us to have a list of your current medications. Please provide a list of your current medications, including any "as needed" medications that you expect to fill in 2022. *Please exclude any OTC meds or vitamins you may take. ------ LIST NAME, DOSAGE AND QUANTITY EXACTLY AS IT APPEARS ON THE BOTTLE ------ IF BRAND IS REQUIRED, type the Rx name-Brand Required in the medication name field. Ex: Lipitor-Brand Required.Spouse/Partner Preference(Required) Prefer to keep my current Prescription Plan if my costs and coverages are similar next year Prefer to change plans because I have been dissatisfied Please provide any details of what you are looking for in a plan (or what you don't like about your current plan) so we can see if there is a more appropriate solution.(Required)Spouse/Partner Shopping Location Preference (choose 1 or both) *(Required) Retail Pharmacy Mail Order 1st Preference - Pharmacy Name(Required) 2nd Preference - Pharmacy Name SPOUSE/PARTNER Number of Prescriptions currently taking(Required)0123456789101112Medication 1 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 2 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 3 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 4 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 5 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 6 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 7 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 8 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 9 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 10 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 11 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medication 12 Name sp(Required) Dosage(Required) Quantity/Filling(Required) Frequency(Required) Every 30 days Every 90 days I only fill once or twice a year Medicare Supplement PlanShopping Medicare Supplement plans can be done any time of year, but typically requires medical underwriting (if you have been enrolled in Medicare longer than 6 months). The best time of year to shop your Supplement is when you receive your annual rate increase letter (typically 45 days before your annual renewal); however, you can change anytime throughout the year for the first of the following month effective date. If you have not had a rate increase since the last time we shopped your rate, the recommendation likely has not changed. People typically find it most effective to shop their Medicare Supplement rates every 3-5 years.Would you like to shop a Medicare Supplement Plan?(Required) Yes No Would you like to shop a Medicare Supplement Plan for your Spouse/Partner?(Required) Yes No YOUR Medical InfoPlease answer the questions and health information below so we may best determine if there is a savings opportunity available. Shopping a Medicare Supplement plan requires medical underwriting (in most states). Your health history can determine if you are eligible to change. Please indicate if you have been diagnosed or treated for any of the following health conditions in the last 10 years.Change Preference (check all that apply)(Required) I want to see if there is a lower premium for the same benefits i have now I would be willing to consider lower benefits to save money Current Plan(Required)Plan GPlan FPlan NPlan High Deductible G (or F)Medicare Advantage PlanOtherUnsureCurrent Premium(Required) Frequency(Required) Monthly Quarterly SemiAnnual Annual Have you recently received a rate increase notice?(Required) Yes No Date of Increase(Required) Premium after Increase(Required) Tobacco Use(Required) Yes No Congestive Heart Failure(Required) Yes No Heart Attack, Stroke or TIA(Required) Yes No Details on CHF, Heart Attack, Stroke or TIA including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Internal Cancer or Melanoma(Required) Yes No Atrial Fibrillation(Required) Yes No Diabetes(Required) Yes No Details on Cancer or A-Fib including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Diabetes with insulin use(Required) Yes No Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)(Required) Yes No Please provide any additional details about diabetes including how long you have had it, have your medications changed in the last 12 months, A1C levels, etc(Required)Kidney or Liver Disease(Required) Yes No Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)(Required) Yes No Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis(Required) Yes No Details on Kidney, Liver, Osteoporosis, Parkinsons, Arthritis or MS including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Any physical, occupational or speech therapy- in past 6 months, current, or recommended?(Required) Yes No Any scheduled or recommended surgery or treatment in next 12 months?(Required) Yes No Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc(Required)SPOUSE/PARTNER'S Medical InfoPlease answer the questions and health information below so we may best determine if there is a savings opportunity available. Shopping a Medicare Supplement plan requires medical underwriting (in most states). Your health history can determine if you are eligible to change. Please indicate if you have been diagnosed or treated for any of the following health conditions in the last 10 years.Change Preference (check all that apply)(Required) I want to see if there is a lower premium for the same benefits i have now I would be willing to consider lower benefits to save money Current Plan(Required)Plan GPlan FPlan NPlan High Deductible G (or F)Medicare Advantage PlanOtherUnsureCurrent Premium(Required) Frequency(Required) Monthly Quarterly SemiAnnual Annual Has your spouse/partner recently received a rate increase notice?(Required) Yes No Date of Increase(Required) Premium after Increase(Required) Tobacco Use(Required) Yes No Congestive Heart Failure(Required) Yes No Heart Attack, Stroke or TIA(Required) Yes No Details on CHF, Heart Attack, Stroke or TIA including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Internal Cancer or Melanoma(Required) Yes No Atrial Fibrillation(Required) Yes No Diabetes(Required) Yes No Details on Cancer or A-Fib including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Diabetes with insulin use(Required) Yes No Diabetes with complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease)(Required) Yes No Please provide any additional details about diabetes including how long you have had it, have your medications changed in the last 12 months, A1C levels, etc(Required)Kidney or Liver Disease(Required) Yes No Osteoporosis and have fractured a bone in last 5 years (regardless of if related to osteoporosis)(Required) Yes No Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis(Required) Yes No Details on Kidney, Liver, Osteoporosis, Parkinsons, Arthritis or MS including date of diagnosis, treatment, ongoing meds needed, degree of recovery, etc.(Required)Any physical, occupational or speech therapy- in past 6 months, current, or recommended?(Required) Yes No Any scheduled or recommended surgery or treatment in next 12 months?(Required) Yes No Details on PT, OT or any upcoming surgeries or treatment including reason for treatment, anticipated recovery time, etc(Required)Medicare AdvantagePlease watch the video on the differences between Medicare Advantage vs Medicare Supplement. You can enter into a Medicare Advantage Plan or change your Medicare Advantage Plan during the Annual Enrollment Period 10/15- 12/7.Would you like to shop a Medicare Advantage Plan?(Required) Yes No Would you like to shop a Medicare Advantage Plan for your spouse/partner?(Required) Yes No Please provide details as to what interests you most about Medicare Advantage. If specific benefits are important to you, please provide details below.(Required)YOUR Program PreferencesMedicare Advantage Plans are network based plans. Answering these questions will help us determine which types of plans may be most suitable to review with you. If a plan looks attractive to you, we will then gather a list of your doctors to confirm they participate with the plan.How do you feel about premium vs medical costs?(Required) 1-The most important thing is low premiums. I am willing to pay more for my medical care if necessary. 2-I am willing to pay a little more to have lower copays and less out of pocket risk. 3-I would prefer to pay more for a plan that will provide little to no out of pocket for my medical bills How do you feel about provider networks?(Required) 1-I don't mind picking my doctors and hospitals from a network listing 2-As long as I can still go to all of my current doctors and hospitals, I am not real picky 3-I would prefer to have freedom of choice of doctors and hospitals Doctor networks can differ from plan to plan (even within the same insurance carrier)Will you need coverage in multiple states?(Required) 1-I don't have a need for access to providers outside of my local area 2-It would be nice to have access to a few providers in other areas, but not a big concern. 3-It is very important for me to have access to providers anywhere in the US Do you have multiple homes, children in other states or simply love to travel and want access to doctors anywhere you go?Are you looking for ancillary benefits?(Required) 1-I want ancillary benefits included in my plan for free (even if it means sacrificing on some other benefits) 2-I would be willing to pay more money for ancillary benefits if it means having better medical benefits. 3-I am not interested in any ancillary benefits Some plans include some benefits for dental, vision, hearing, gym memberships and maybe even discounts on things like OTC meds or vitamins.How do you feel about managed care?(Required) 1-I don't mind managed care in exchange for lower premiums 2-I have no preference 3-I do not want the insurance company to have any authority over my care Managed care is the insurance company working with your doctors to manage your care needs. Plans with managed care require prior authorization or approval on some services.Would your answers change if you were in poor health?(Required) 1-I prefer to save money now knowing I may not have access to lowest out of pocket plans later 2-I have no preference 3-I would rather pay more now to know I will be in a flexible plan with low medical costs if needed in the future Once your are diagnosed with certain medical conditions, some plans may not be available for purchase in the future. SPOUSE/PARTNER'S Program PreferencesMedicare Advantage Plans are network based plans. Answering these questions will help us determine which types of plans may be most suitable to review with you. If a plan looks attractive to you, we will then gather a list of your doctors to confirm they participate with the plan.How do you feel about premium vs medical costs?(Required) 1-The most important thing is low premiums. I am willing to pay more for my medical care if necessary. 2-I am willing to pay a little more to have lower copays and less out of pocket risk. 3-I would prefer to pay more for a plan that will provide little to no out of pocket for my medical bills How do you feel about provider networks?(Required) 1-I don't mind picking my doctors and hospitals from a network listing 2-As long as I can still go to all of my current doctors and hospitals, I am not real picky 3-I would prefer to have freedom of choice of doctors and hospitals Doctor networks can differ from plan to plan (even within the same insurance carrier)Will you need coverage in multiple states?(Required) 1-I don't have a need for access to providers outside of my local area 2-It would be nice to have access to a few providers in other areas, but not a big concern. 3-It is very important for me to have access to providers anywhere in the US Do you have multiple homes, children in other states or simply love to travel and want access to doctors anywhere you go?Are you looking for ancillary benefits?(Required) 1-I want ancillary benefits included in my plan for free (even if it means sacrificing on some other benefits) 2-I would be willing to pay more money for ancillary benefits if it means having better medical benefits. 3-I am not interested in any ancillary benefits Some plans include some benefits for dental, vision, hearing, gym memberships and maybe even discounts on things like OTC meds or vitamins.How do you feel about managed care?(Required) 1-I don't mind managed care in exchange for lower premiums 2-I have no preference 3-I do not want the insurance company to have any authority over my care Managed care is the insurance company working with your doctors to manage your care needs. Plans with managed care require prior authorization or approval on some services.Would your answers change if you were in poor health?(Required) 1-I prefer to save money now knowing I may not have access to lowest out of pocket plans later 2-I have no preference 3-I would rather pay more now to know I will be in a flexible plan with low medical costs if needed in the future Once your are diagnosed with certain medical conditions, some plans may not be available for purchase in the future. Other CoveragesDo you have interest in any other types of benefits (check all that apply) Dental Vision Long Term Care (Nursing Home or Home Care) Please provide any additional details that you think would be important to know about what you are looking to do this year with your plans Differences between Medicare Supplement and Medicare Advantage - 10m10s How do I know what insurance I have – 2m11s Who needs to take action during AEP - 3m36s How to best prepare for AEP – 6m47s Prescription Plan choices with MS and MAPD - 2m8s When is the best time to shop my MS Plan – 2m23s What if I don’t want to change my plan – 5m32s Important Dates - 1m27s
