The Medicare Channel Prescription Drug Quote Request Form

Send Us Your Prescriptions:

Please submit your prescriptions below and we will use a Prescription Drug Tool to find the RX Part D Plan with the lowest annual total cost and contact you with a suggestion.

If you have any questions please call us 1-800-728-9609

Call to speak to an agent 1-800-728-9609

Click here to start your free quote.

As an independent agent we have the lowest rates.

We still like to provide good old fashioned customer service.

Name

Phone

E-Mail

Please enter the county in which you live. Example: Fulton, Tarrant, etc.

Please select the state where you are located

Please enter your zip code.

Please enter your birthday (MM/DD/YYYY)

Example: Lipitor

Example:10 mg

Example: 1 X day

If you select other dosage please explain in the additional comments section below. Please also submit a separate request for your spouse.

Medication #1 Dosage Frequency

Medication #2 Dosage Frequency

Medication #3 Dosage Frequency

Medication #4 Dosage Frequency

Medication #5 Dosage Frequency

Medication #6 Dosage Frequency

Medication #7 Dosage Frequency

Medication #8 Dosage Frequency

Medication #9 Dosage Frequency

Medication #10 Dosage Frequency

Additional Comments About Your Prescriptions/Or Questions: