AEP Request Form - YourMedPlan.com

Please complete this form so we can research the proper 2023 plans for you.

Although we have most of your information regarding your prescriptions and doctors, Medicare is requiring us to collect the information again so we can confirm if your current plan is still the better option.

After you complete the form we will send you a permission slip called a “Scope of Appointment.” It will come via email from DoNotReply@drx.com within a few days. Medicare requires us to send a new one every year for us to give you a recommendation. Please be on the lookout for it.

Once you complete your Scope of Appointment, we will research plans and prepare our recommendation. Our recommendation will also come via email from DoNotReply@drx.com.

From there, you can tell us which plan you’d like and we will process the application for you. You can also schedule a follow-up call with us if you’d like.

Thank you for your partnership with us through this process! We appreciate your trust in us as your agents of choice. 🙂

Note: the info we have on file for you will auto-populate once you enter your email address. If it is out of date or incorrect please enter the correct details.

If you and your spouse are both clients, you can open this link multiple times to submit a form for each of you.

Email Address

First Name *

Last Name *

Your Best Phone Number

Address

Address 2

City

State

ZIP Code

County

Which type(s) of policies would you like us to research for you?

Medicare Advantage (Includes Prescription Drug Coverage)

Part D (Prescription Drug Coverage)

OtherOther

Please provide your current medications one at a time. Click “Add” below to add multiple medications.

Do you take the brand name or the generic of this medication?

Brand Name

Generic

Brand Name

Dosage

Generic Name + Dosage

Dosage Form

Quantity Per Month

If you can’t find your drug in the provided list, add it here. Please include dosage, form of the drug, and how often you take it.

Add Remove

Please provide your current doctors. Click “Add” below to add multiple doctors.

First Name

Last Name

Address where this doctor sees you

City

State/Province

Zip/Postal

Add Remove

What is your preferred pharmacy?

Anything else you’d like us to know?