YOUNG’S INSURANCE SERVICES, INC.

2950 Felton Rd. * Suite 204 * East Norriton, PA 19401 * Office # 610-275-7923 * Fax # 610-275-7925
E-Mail me at jlong@yisonline.com * View my website at www.yourmedicarespecialist.com

Medicare Part D/MA Prescription Annual Review Sheet (please submit one form per person)
Drug Plans, premiums, co-pays, and formularies change each year from company to company. If you would like us to review your current Rx plan through
the Medicare Plan Finder, you may list out your prescriptions below. I will contact you within a few weeks with the results.
This is a complimentary service offered to our clients by our agency and is completely optional.

Your Name: Your Address:

Your Phone # Your Agent’s Name: James Long Are you enrolled in PACE or PACENET?

What company do you currently use for your Rx Plan? Did you go into the donut hole?

Do you use mail order? Can you take generics? (*Please note below if name brand is necessary)

What company do you have for health insurance?

Prescription Name (Include XL, CR, XR, HCT etc.) Dosage Times taken Prescription Name (Include XL, CR, XR, HCT etc.) Dosage Times taken

EXACT SPELLING NECESSARY! a day EXACT SPELLING NECESSARY! a day

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