Rx Drug Lookup | Assurance Network

Helpful to have ready

Each medication’s exact name and strength
How often you take it
Your preferred pharmacy, and whether mail order is OK
Doctors and specialists you want to keep

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

Prefer to talk? Call 804-299-4075.

Your details

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? Yes No

Medications

Drug Name

Dosage

How Many

Times per Day

Drug Name

Dosage

How Many

Times per Day

Drug Name

Dosage

How Many

Times per Day

Doctors you want to keep (optional)

Doctor's name

Specialty

City

ZIP Code

Comments / additional drugs or doctorsPlease do not include your Social Security or Medicare number.

◆ Your information is kept private and secure. We do not sell, rent, or trade your personal information to third parties for monetary or other valuable consideration.

Not affiliated with or endorsed by the federal government, Medicare, or the Social Security Administration. This page provides general Medicare education. Social Security or the Railroad Retirement Board handles enrollment in Parts A and B.