Rx Drug Lookup

Rx Drug & Doctor Form

To review your situation and provide plans and pricing information, complete the Rx Drug/Provider Lookup below.

Rx Drug Lookup Form

Complete the below form and I will contact you as soon as possible.

First Name

Last Name

Email Address

Phone Number

ZIP Code

What is your preferred pharmacy?

Are you open to having your prescriptions mailed to you, if it saves you additional money?

Medication 1

Drug Name

Dosage

Times Per Day

Medication 2

Drug Name

Dosage

Times Per Day

Medication 3

Drug Name

Dosage

Times Per Day

Medication 4

Drug Name

Dosage

Times Per Day

Medication 5

Drug Name

Dosage

Times Per Day

Medication 6

Drug Name

Dosage

Times Per Day

Medication 7

Drug Name

Dosage

Times Per Day

Medication 8

Drug Name

Dosage

Times Per Day

Medication 9

Drug Name

Dosage

Times Per Day

Medication 10

Drug Name

Dosage

Times Per Day

Provider 1

First Name

Last Name

ZIP prescriptions Per

Specialty

City

ZIP Code

Provider 2

First Name

Last Name

Specialty

City

ZIP Code

Provider 3

First Name

Last Name

Specialty

City

ZIP Code

Provider 4

First Name

Last Name

Specialty

City

ZIP Code

Comments / Additional Drugs or Doctors

By providing your telephone number and submitting the form you're consenting to be contacted by SMS text message. Messaging frequency may vary. Message & data rates may apply. Reply STOP to opt-out of further messaging. Reply HELP for help. Privacy Policy I Terms and Conditions

I agree

By completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare plans. This is a solicitation for insurance.

Get In Touch with Me!

Email

mary@maryaliceinsurance.com

Office Phone

919-410-7272

Serving NC

I do not offer every plan available in your area. Currently, I represent 9 organizations which offer over 80 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options. This is a proprietary website and is not associated, endorsed or authorized by the Social Security Administration, the Department of Health and Human Services or the Center for Medicare and Medicaid Services. This site contains decision-support content and information about Medicare, services related to Medicare and services for people with Medicare. If you would like to find more information about the Medicare program please visit the Official U.S. Government Site for People with Medicare located at http://www.medicare.gov

Mary Alice Insurance Solutions

Insurance Guidance With a Caregiver’s Heart. I provide personal guidance to help you understand your Medicare and other insurance options to protect you current and future care needs.

Rx Drug & Doctor Form

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