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Annual Plan Review
Step
1
of
9
- Scope of Appointment Confirmation
11%
Is your Scope of Appointment Complete?
*
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No
Name
*
First
Last
Phone
Email
*
Birth Date
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State
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Preferred Communication Method
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Email Address
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SMS Phone Number
*
SMS Text - By providing your phone number and checking the box, you agree to receive promotional and marketing messages, notifications, and customer service communications from SMS Text. Message and data rates may apply. Consent is not a condition of purchase. Message frequency varies. Text HELP for help. Text STOP to cancel.
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Current Plan Type
*
Medicare Supplement
Medicare Advantage
Employer or Retiree Group
Other
Current Health Plan Name
*
Current Health Plan Premium
Prescription Drug Plan
Skip if you are on Medicare Advantage that includes Part D.
Prescription Drug Plan Premium
Preferred Pharmacies:
*
Do You Use Mail Order Pharmacy?
Yes
No
If Yes, Which Pharmacy?
Primary Care Physician & Facility
*
Preferred Networks (i.e., Aurora, Froedtert, Prohealth)
*
Provider Information:
Please list your other doctors including their specialty and facility.
Prescription Information:
Please include the name of the medication as it appears on your prescription bottle or container.
Actively Taking Medication?
Yes
No
Financial Needs
*
Have you recently qualified for additional financial assistance including Low-Income Subsidy or Medicaid?
Select Option
LIS
Medicaid
No
Unsure
If Yes, What Do You Qualify For:
Rate Your Current Plan
Select Option
5 - Very Satisfied
4 - Somewhat Satisfied
3 - Neutral
2 - Somewhat Dissatisfied
1 - Very Dissatisfied
Additional Comments:
Do You Plan On Keeping Your Current Medicare Plan?
*
Select Option
Yes
No
Unsure
Any Issues Receiving Services From Your Current Providers?
Yes
No
If Yes, Please Explain:
Any Issues Receiving Services From Your Pharmacy?
Yes
No
If Yes, Please Explain:
How Likely Are You To Recommend Sovereign Select To A Friend Or Loved One?
Select Option
5 - Very Likely
4 - Somewhat Likely
3 - Neutral
2 - Somewhat Unlikely
1 - Very Unlikely
Please Note Any Additional Questions Regarding Your Health Coverage:
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