If you would prefer to download our fill-in PDF file to update your medication list, please click the button below. Once completed, you can fax, email, mail, or personally deliver the list at your earliest convenience.
Thank you for updating your Medicare covered Prescription drug list for the upcoming plan year!
Please use the following form to change the dosage or frequency of an existing medication or to provide the name, dosage, frequency and type of a new medication.
If you have additional changes to be made, please click submit and you'll be redirected to a new blank form where you can make the remaining changes.
If your contact information has changed, please contact our office so that we may update our records.