Tell us about your current Medicare coverage.

Medicare Part A & B Number

Part A Effective Date

Part B Effective Date

Do you currently have Medicare insurance?

MA / MAPD

Medicare Supplement + Part D (PDP)

No PDP

Are you on LIS (Low Income Subsidy) or Medicaid?

Yes

Last step — your medications and a quick confirmation.

Medications Details

Medications 1

Dosage 1

Prescribing Doctor 1

Phone Number 1

Fax Number 1

Single or Married?

Single

Married

Do you meet the Social Security income guideline?

Single: $23,475/year ($1,956/month)

Married: $31,725/year ($2,643.75/month)

By checking this box, I give MedicareRxHelp permission to contact me by phone, email, and SMS regarding this program. I understand this is not insurance, is not a discount card, and is not affiliated with Medicare or CMS in any way. My information is collected only for the purpose of working with me on this program and will not be sold.