Your doctor and drug list
Fill this in before you compare plans or call us. It helps us check that your doctors and medicines are covered. Print it, or keep it by the phone.
About you
- Your ZIP code
- __________
- Your plan now (name on your card)
- ______________________________
- Your pharmacy (name and city)
- ______________________________
- Do you get Medicaid or Extra Help?
- Yes / No / Not sure
Your doctors
Include specialists, therapists and any hospital you want to use.
| Doctor or place | Kind of care | City | Must keep? |
|---|---|---|---|
| Yes / No | |||
| Yes / No | |||
| Yes / No | |||
| Yes / No | |||
| Yes / No |
Your prescriptions
Copy the name and strength from the bottle. Include inhalers, insulin, eye drops and shots.
| Drug name | Strength (for example, 10 mg) | How often | 90-day supply? |
|---|---|---|---|
| Yes / No | |||
| Yes / No | |||
| Yes / No | |||
| Yes / No | |||
| Yes / No | |||
| Yes / No |
What matters most to you?
Circle any: low monthly cost / low cost when I see a doctor / keep my doctors / dental / vision / hearing / travel outside Florida / help with groceries or rides.
Keep it private
Do not write your Medicare number or Social Security number on this list. We only ask for your Medicare card when you choose to enroll. Learn more on our fraud protection page.