Annual Plan Review – Sovereign Select, LLC

Name*

First Last

Primary Address*

Street Address Address Line 2 City State ZIP Code

Secondary Address

Street Address Address Line 2 City State ZIP Code

Primary Phone Number*

Secondary Phone Number

Email*

If you don't have an email, please type NONE in the box.

Current Plan*

Current Prescription Plan (if applicable)

Preferred Pharmacies*

Do you use a mail order pharmacy?*

Yes
No

If yes, which pharmacy?

Primary Care Physician and Facility*

Preferred Network (Aurora, Froedtert, Prohealth, etc)*

Provider Information

Please list your other doctors including their specialty and facility. Example: Dr John Doe - Cardiologist - Froedtert Health

Prescription Information*

Please include the EXACT name of the medication as it appears on your prescription bottle/container. Please include the TYPE (tablet, capsule, injection, inhaler, etc), the DOSE of the med, the FREQUENCY (how often you take the med - daily, twice daily, etc), the AMOUNT in one prescription and HOW OFTEN you have it filled (30 days, 90 days, twice a year, etc). Please do NOT include over the counter medication such as vitamins, Tylenol, Advil, etc. *If you do NOT take any prescription medications, please type NONE in the box below.* Please enter information like this: Name of Medication - Type - Dose - Frequency - Amount - How often filled

Please take a few moments to complete the Plan Survey below.

Have you recently qualified for additional financial assistance including Low-Income Subsidy or Medicaid? (Programs that help pay for prescriptions and/or health care costs)*

Yes
No

If yes, what do you qualify for?

How would you rate your current plan?*

Comments:

Do you plan on keeping your current Medicare plan for 2020?*

Yes
No

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

Yes
No

If yes, which one(s)?

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

Yes
No

If yes, what issues are you having?

AEP ends December 7th!

We would like to make sure we have your current information in our system. Please take a few minutes to fill out these forms and submit them to us.

Current Information Update Request-Tom Qualley

Please take a few moments to complete the Plan Survey below.

Thank you for completing our Annual Plan Review and Survey! We will review this information and be in contact with you soon.