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Coverage Interests

Current Prescriptions

DO NOT list over the counter (OTC) vitamins, supplements, and/or prescriptions not purchased.
DO NOT state "as needed". Instead, provide an estimate based on the frequency you use the drug.
For inhalers, eye drops, creams, lotions, or ointments, provide size of bottle/tube and frequency of refills.
For insulin or injectables, provide units per day or pens per month.
Drug Name Dosage Package Generic Actions
       

Additional Information

By responding to this request, I understand that I am not required to provide any private, protected health information (PHI). This information is only for use by Silver Solutions Insurance Group to help make an informed plan decision and will not be shared with any third party. I agree that an Silver Solutions Insurance Group representative may contact me by telephone, e-mail or US mail to discuss Medicare Advantage Plans, Prescription Drug Plans and Medicare Supplement Insurance Plans.