Please complete this medication form so that we can help determine the most effective Medicare prescription drug plan for you.

By completing this form, you are authorizing Insurance Specialists Group Agents to analyze your prescription drug utilization and are requesting a recommendation for your Part D Prescription drug coverage or Medicare advantage plan and authorizing to receive a call and/or an email regarding my Prescription drug coverage options.

I understand that I am volunteering this prescription medication information to evaluate my prescription drug coverage options. This information is completely confidential.