My Prescription Drug list
Fill this form with all medications you are taking and I will run all plans to see which plan(s) will provide the best coverage for you. Don't forget to hit the submit button at the bottom when done.
If you can,
as this form will be required, so we can skip that step later if it's done now.
Sign in to Google
to save your progress.
* Indicates required question
Who is your preferred doctor?
What is your preferred pharmacy?
Prescriptions, Dosage, and how many per day/month?
List all medications here. Example:
Losartan, 10mg, 1x
. Hit <ENTER> for a new line.
Notes: Is there anything you think I should know while looking for plans?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service