Medicare Plan Wish List Request

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

You are interested in (select all that apply):(Required)

Medicare advantage plans (Medicare compliant individual health plan)

Medigap (Supplement) plans (Secondary medical coverage to Original Medicare)

Part D stand-alone plans (to add to Original Medicare with/out a Medigap plan)

Not Sure

Plan Preferences (What would you like from your coverage? Select all that apply)

I prefer to keep Original Medicare as primary coverage, possibly adding a Medigap (supplement) and/or Part D (prescription coverage)

Includes prescription coverage (Part D) (Some coverages do not include drug coverage)

Provides greater medical coverage (lower out of pocket costs for medical care, fewer "Extra" benefits)

Generally provides greater "Extras" benefits (Higher medical costs, focuses on benefits like dental, over the counter benefits (OTC), gym programs, etc.)

Provides greater coverage for Diabetics, Heart and Cardiovascular disorders (C-SNP)

I prefer a HMO plan (Managed care, may require referrals, in network providers, coverage within the service area (except urgent care and ER))

I prefer a PPO plan (Allows in and out of network benfits, no referrals required, may include multi-state coverage)

Includes preventive dental coverage only (Basic coverage: cleanings, check-ups, x-rays, etc.)

Includes comprehensive dental coverage (Provides preventive, basic and major procedure coverage)

Includes vision hardware benefit (Provides a benefit for eyeglasses or contacts)

Includes gym program (Example: Silver Sneakers, Silver & Fit, OnePass, etc.)

Includes hearing hardware benefit (Provides copays or an allowance for hearing aids)

Includes over the counter (OTC) benefit (Allows you a budget to purchase over the counter items)

I qualify for Medicare AND Medicaid (Provides Medicare and Medicaid benefits in one Medicare advantage plan)

Prescription List

Drug Name (ex: Lisinopril)

Dosage (ex: 10mg)

Frequency (ex: 1x daily)

Please enter your prescription list, excluding any over the counter supplements, etc. To add more prescriptions, click the + icon at the end (on the right) of the previous prescription entry. If none, please enter N/A in the first space.

Preferred Pharmacy

Name of Preferred Pharmacy

Provider List

Provider First Name

Provider Last Name

Provider Type (MD, DDS, etc.)

Group Affiliation, if known (Optum, MultiCare, etc.)

Please list care providers you wish to continue services with. To add more providers, click the + icon at the end (on the right) of the previous provider entry. If none, please enter N/A in the first space.

Plan Level Preference

Medigap (supplement) plans come in different plan levels, please select the plan level you are most interested in.

Plan A

Plan B

Plan D

Plan G

High deductible Plan G

Plan K

Plan L

Plan M

Plan N

I'm not sure

Questions/Comments/Notes

Please provide any other information that may help with shopping coverage, otherwise click the NEXT button below to continue.

Consent(Required)

By checking this box, you are providing permission to contact you regarding services and products offered by Benefit Solutions Plus, LLC. Any information provided will be used for internal use only. I understand that Benefit Solutions Plus, LLC is bound under regulations to keep all personal information private, and will not sell personal information to any third party company.

I agree

CAPTCHA

Medicare Coverage Wish List Request Form