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Annual Medicare Review

Complete our Annual Medicare Review form below and a member of our team will reach out to you between October 15th – December 7th.

Full Name*
Address*
Email
Phone*
List of Prescription Medications (please list the complete name of medication as shown on your prescription including dosage and quantity per day. Example: Metoprolol Succinate ER, 50 MG, 1 x daily) If no current medications type “none”.*
Preferred Pharmacy (list the pharmacy name you use to obtain your prescriptions. If you prefer mail order, please provide a pharmacy name in the event you would need to go to a pharmacy)*
Do you ever use mail order?
- Yes
- No
Current Prescription Plan (please provide name of plan and premium if known – i.e. Wellcare Value Script - $12.90. If unsure, type “unknown”)*
Would you also like us to review your Medicare Advantage Plan? Note: Medicare Supplements can be reviewed any time of the year.*
- Yes
- No
Is there anything else you would like us to know, or to take into consideration?
NOTE: Once you hit the submit button, if you are submitting an additional review, please close the web browser and start the process over from step 1.
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Douple Agency, Inc.

34 East Main Street
Ephrata, Pennsylvania 17522

Phone: (717) 733-8631

Mon-Fri: 8:30am-5:00pm
Sat-Sun: Closed

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