Annual Plan Review – Sovereign Select Insurance

Name*

First Last

Phone

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Birth Date

Is your current health insurance a:

Current Health Plan Name*

Current Health Plan Premium

Current Part D Prescription Plan Name

Current Part D Plan Premium (Skip if your Part D is included in your health plan)

Preferred Pharmacies*

Do you use a mail order pharmacy?*

If yes, which pharmacy?

Primary Care Physician & Facility*

Preferred Network/s (i.e., Aurora, Froedtert, Prohealth)*

Provider Information

Please list your other doctors including their specialty and facility.

Prescription Information

Please include the name of the medication as it appears on your prescription bottle or container.

I don't take any Medications.

Financial Needs*

Have you recently qualified for additional financial assistance including Low-Income Subsidy or Medicaid?

If yes, what do you qualify for?

Rate Your Current Plan*

Comments:

Do you plan on keeping your current Medicare plan?*

Are you having any issues with receiving services from your providers?*

If yes, which one(s)?

Are you having any issues with receiving services from your pharmacy?*

If yes, what issues are you having?

Is there anything you think we should know for your review? Feel free to provide more information and details here.

Total

$0.00