We need to look at your Med list

and how the New Part D changes for 2025

are going to affect you...

Fill out this form and we will be in touch with you the

middle of October to let you know what

plan recommendations are for you.

Current Client Part D Drug list

Name:

Nickname:

Who is your Medicare Advisor?

Chris Curtis

Jody Curtis

Jim Spalding

Tanner Curtis

DOB:

Cell Phone:

Email:

Zip Code:

City

Name of Current Drug Plan (look on your drug card)

Cost of your Current Drug Plan per month

List ALL of your Prescribed Medications you take: (actual name on the bottle, dosage, how many per day) EXAMPLE: Lisinopril 10mg 1xday Metformin 1000mg 2xday

Pharmacy of Choice

How much if your Medicare Supplement per month right now?

Do you get any special shots or infusions at a doctors office? - this does NOT count vaccinations

Yes

Free Text

Great job, Thank You for filling it out,

The new plans get released on Oct.1st.

We will take the next 2 weeks and run your medication list along with a couple of hundred others... :-)

We will be back in touch with you on what we recommend for you for 2025. Please be patient...

Your Medicare Planning Advisors,

Chris Curtis

Jody Curtis

Jim Spalding

Tanner Curtis

Medicare Planning of Dayton

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