Everence review of available Medicare Part D plans

Please complete the following steps to work with the Everence Part D Service Center to review your available Medicare Part D plans:

  1. Complete this form, including information on all prescription medications if applicable;
  2. Submit payment, a $50 fee will be charged at the end of this form;
  3. Follow link in confirmation email to schedule review appointment.

Your form will not be saved until you have entered the required information and submitted payment. Information will be lost if both steps are not completed.

Do you receive assistance for medications through any programs? (E.g., ExtraHelp, VA, state government programs, etc.) *
Do you currently have prescription medications? *
List current prescription medications, not including over-the-counter drugs, vitamins, herbals, or supplies. This information is used only to help research available Part D prescription drug plan options. List only current prescription medications. 
Prescription medication 1
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 2
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 3
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 4
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 5
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 6
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 7
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 8
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 9
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 10
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 11
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 12
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 13
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 14
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 15
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 16
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 17
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 18
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 19
30-day or 90-day supply *
 
Add another prescription? *
Prescription medication 20
30-day or 90-day supply *
 
Acknowledgments
  • For a fee, Everence will help you identify and evaluate Medicare Part D Plans using Medicare’s website.
  • The assistance Everence provides is based on the information you provide in this form and information on Medicare’s website. Everence does not verify this information.
  • Everence will not select a plan for you. You are responsible for selecting a plan that’s appropriate for you.
  • At your request, Everence will enroll you in the Medicare Part D prescription drug plan you select.
  • Everence does not issue or service Medicare Part D plans. The company that sponsors the plan you select will service your plan.
To proceed with Everence’s review of your available Medicare Part D plans, you must check the following box before submitting this form. Read the statement next to the box before checking it. *
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Did an Everence representative help you complete this form? *