D & D Insurance - Medicare Part D Insurance Quote - Insurance

D & D Insurance Agency Inc.

Medicare Part D

Personal Information
First Name	Last Name
Address1

City	State Zip
Home Telephone	Email Address
The Following Medicare Advantage plans (HMO'S, PPO'S, Private Fee-For-Service) are available and offer prescription drug benefits.
Please check the box next to each plan you would like information from
HUMANA
SECURE HORIZONS
BLUE CROSS/BLUE SHIELD
The following Medicare Part D - Prescription Drug plans are available in your area These are stand alone Prescription plans
Please check the box next to each plan you would like information from


HEALTH NET
HUMANA
PRESCRIPTION PATHWAY
PACIFICARE
COVENTRY HEALTH CARE
ADVANTRA RX
UNITED HEALTH CARE
ASURIS NORTHWEST HEALTHCARE
COMMUNITY CARE RX
UNITED AMERICAN
Coverage amount or limit of liability requested

Are you currently in Medicare Part A and Part B?	Yes	No
If not yet enrolled, will you turn 65 within the next 3 months?	Yes	No
Are you enrolled in a Medicare Part D Prescription Drug Plan (PDP) or Medicare Advantage Prescription Drug (MA-PD) plan?	Yes	No
Are you currently covered under group health insurance provided by an employer, union, or retirement plan?	Yes	No
If 'Yes' to question 3: Do you have prescription drug insurance provided by an employer, union, or retirement plan?	Yes	No
Are you currently a Medicaid recipient( Medi-Cal in CA)?	Yes	No
Do you expect to change your permanent address within 6 months?	Yes	No
Do you have a spouse enrolled in Medicare Part A or Part B or who is turning 65 within 3 months?	Yes	No
Have you been diagnosed with End-Stage Renal Disease?	Yes	No
(only answer this question if requesting Prescription Drug Plan information) If your annual income is below $15,000 you may qualify for additional prescription drug subsidies. If you think you may qualify, click 'Yes'.	Yes	No



Due to heavy volume of requests for Part D information, we encourage you to include your email address above for a faster response from the Part D plans you select. Your email address will only be provided to the plans you select.