Prescription List | Acadiana Senior Advisors

Part D

Prescription Drug List

This form is to help expedite your Part D Prescription Drug Plan (PDP) research

Please complete the form entirely so that we can help you find the best plan for you!

FORM NAME: PDP Form

First Name

Last Name

Phone Number

Street Address

Address Line 2

City

State

Zip

Do you receive "Extra Help" from Medicaid or Social Security?

No Yes Not Sure

Do you currently take any prescription medications?

Yes No

If yes, please list Medication Drug Name(s) and Dosage(s), how many per day, name brand or generic, type (capsule, tablet, cream, etc..) and how often you refill:

Example: LISINOPRIL 20mg 1x day, generic, tablet, every 3 months; ROSUVASTATIN 5mg 1x day, generic, tablet, monthly; TRULICITY 1.5mg/0.5ml, 4 pens, name brand, injection, every 2 months

What is your preferred pharmacy?

Do you currently or would you consider using mail order pharmacy?

No Yes

Would you consider changing pharmacies if prices were lower?

No Yes

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Your information is safe and will not be shared. It is only used in our secure system to shop for the best plans available to you.

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