Annual Enrollment Medicare Advantage What is needed for Annual Enrollment Medicare Advantage? Yearly update on your Medicare coverage and options Supports decision-making during open enrollment Allows listing of prescriptions and special doctor requirements Lets you indicate interest in reviewing or changing plans Safeguards all data, using it only to refine your coverage recommendations Annual Enrollment Medicare Advantage Newsletter Personal InformationTell us who needs coverage so we can match you with the right plans.First NameLast NameEmailPhone NumberZip CodeCountyMailing address different from residential address? Yes NoMailing AddressDate of BirthTobacco User? Yes NoCurrent Coverage InformationWhat are your thoughts regarding your current coverage for your current plan? I am happy with my medicare advantage plan and want to renew it if still available I’d like to review medicare supplement options I’d like to review other Medicare advantage optionsDo you live with someone else in the household? Yes NoWould you like quotes using an EFT discount, or do you prefer check or debit/credit card payment? EFT (discount may apply with this option) Mail in a check, credit or debit cardPlease describe what you liked or did not like about your previous plan? Please select 3 benefits that you prioritize.DentalVisionHearingAdditional telehealthDiabetes supplies and servicesOver-the-Counter itemsFitnessPart B GivebackTransportation5-Star RatingWhat network types are you interested in? (Select all that apply)HMOPPOPharmacyPreferred pharmacyPrescription InformationPlease list any prescriptions you are taking that you want to make sure are covered — names, doses and frequenciesProvider InformationPlease list any providers that need to be in-network with your current plan or other plan options I agree to the Terms and Conditions and Privacy Policy. Radio Field Yes NoSubmit Questionnaire
