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Annual Plan Review Step-by-Step
Step-by-Step Review:
Step
1
of
9
- Scope of Appointment Confirmation
11%
Is your Scope of Appointment Complete?
*
Yes
No
Name
*
First
Last
Phone
Email
*
Birth Date
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State
Select Option
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Preferred Communication Method
Email
Phone
Mail
Text
Subscribe
*
indicates required
Email Address
*
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.
See terms
.
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:
Hidden
Agent Name
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