HomeMy WebLinkAboutMedicare Plan Review Info Form 2020.1Medicare Plan Review Information Form
1. What is your name on your Medicare card and address on record with Medicare?
First ______________________________ M.I. ______ Last _____________________________
Address ________________________________________________________________________
City _____________________________ Zip Code ___________ County ___________________
Phone ___________________________ Email ________________________________________
2. What is the best way for us to contact you regarding follow-up questions and/or scheduling?
□ Phone □ Email □ Text message □ Other __________________________
3. What is your date of birth (mm/dd/yyyy)? ________________________________________
4. What is your current drug coverage? □ None □ VA
□ Medicare Part D Drug Plan: Name of Plan ___________________________________
□ Medicare Advantage Plan: Name of Plan ____________________________________
□ Employer/Retiree Plan ____________________ □ Other ____________________
5. Are you satisfied with your current prescription drug plan and/or Medicare Advantage plan?
□ Yes □ No □ Not sure □ I don’t have one
Please explain: ___________________________________________________________
________________________________________________________________________
6. Is your income above or below the following amounts ?
• Individual: $19,380/year ($1,615/month) • Couple: $26,100/year ($2,175/month)
□ Above □ Below
7. Do you currently receive any of the following benefits?
_____ Medicaid (Title 19 – MEPD, SSI, Elderly Waiver, Medically Needy Spend-down, Nursing Home)
_____ Help paying your Medicare Part B premium (QMB, SLMB, QI)
_____ Extra Help with your Medicare drug costs
8. What pharmacy do you prefer? You may list two:
_____________________________________________________________________________
Name of Pharmacy Address and City Phone Number
_____________________________________________________________________________
Name of Pharmacy Address and City Phone Number
9. Would you consider changing pharmacies if it saves you money? □ Yes □ No
This form contains confidential information and will not be shared with anyone other than your SHIIP counselor(s).
Required Information for a Medicare Comparison
The Senior Health Insurance Information Program (SHIIP) is sponsored by the State of Iowa Insurance Division.
SHIIP uses the Medicare.gov Medicare Plan Finder to compare Medicare Part D and Medicare Advantage drug
plans for individuals. In order for SHIIP to do a comparison for you, you will need to have an online user
account with MyMedicare.gov and provide your username and password to SHIIP. An online user account
allows you to save your drug list, make updates from year-to-year, and easily compare drug plans. If needed,
we can help you create an account to do your comparison(s).
□ I have a MyMedicare.gov account (complete this section):
Please provide your username and password for your MyMedicare.gov account. We will only
use this information to do a Part D or Medicare Advantage comparison for you. Write legibly
and be sure to show uppercase and lowercase letters correctly:
Username: ________________________________________________
Password: ________________________________________________
□ I DO NOT have a MyMedicare.gov account and need help creating one
If you don’t have a computer or internet access, or if you otherwise need assistance,
a SHIIP volunteer will contact you to help set up an account.
How to create your official MyMedicare.gov account:
- Go to https://www.mymedicare.gov/
- Click “create an account now” under the Log in to your account header
- Complete the fields on this page, entering your:
o Medicare number with no spaces or dashes
o Last name and suffix (if any), exactly as shown on your Medicare card
o Email address (you will need to re-enter it to confirm)
o Date of birth
o 5-digit zip code
o Part A coverage start date from your Medicare card (if you don’t have Part A, click the
“Switch to Part B” link and enter your Part B coverage start date instead)
- Read and check both boxes at the bottom of the page, then click “Next”
- A security notice will appear on the same page; click “OK” to continue
- You will need to create a username and password following these guidelines:
o Username (we suggest using your email address as your username)
▪ must be 8-30 characters with no spaces; must include at least 4 letters
▪ can include letters, numbers and these special characters: @ ! . - _ $
▪ don’t use special character as the first or last character of your username
▪ Examples: JohnDoe@gmail.com - or - John Doe!1954
o Password (you will need to enter and re-enter your password to confirm)
▪ must be 8-16 characters; must contain at least one letter and one number
▪ must contain one or more of these special characters: @ ! $ % “ * ( )
▪ cannot contain your username, Medicare number, or Social Security number
▪ Example: Howdy$19
- Select a security question from a dropdown list and enter your answer
- Click “Submit,” and now you can log in to your account
o Medicare will mail you a confirmation letter within 10-14 days
This form contains confidential information and will not be shared with anyone other than your SHIIP couns elor(s).