The Porter Group Client Drug List for Annual Enrollment Name(Required) First Last Your Phone #:(Required)Email County you live in:(Required) Your Zip Code:(Required) Your Current Medicare Plan:(Required) Do you receive Extra Help?(Required) Yes No I'm not sure Medication(Required)Medication Name (example: Lipitor)Dosage (example: 20mg)Frequency (example: Once Daily) Add RemovePharmacies you prefer: Please list at least 3.(Required) Add RemoveJust as important as it is to review your medications, we need to make sure your pharmacy is listed as standard or preferred with carrier.Changes: Address Household Income Other (please list) Changes Add Remove
