Online Medicare Sign Up

Medicare Open Enrollment

OCTOBER 15TH THROUGH DECEMBER 7TH
SCOTT PHARMACY'S ONLINE FORM WILL BE ACTIVE AGAIN IN THE FALL OF 2026.

THANK YOU!!
Section 1: Medicare Beneficiary
Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Phone Number:
Format: (000) 000-0000.
Email
example@example.com
Would you like to add a spouse or significant other?
Name of spouse/significant other:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Are you a current or new Scott Pharmacy patient (New patients will need an up-to-date medication list for the review)?
Do you currently have a Medicare Advantage/Complete Plan (Medicare Part C), OR would you like to learn more about these plans by having a licensed insurance agent contact you?
How would you like to have the review preformed? *Pharmacy prefers phone.

Other
Will you be gone for vacation/winter months during open enrollment (open enrollment period: October 15th thru December 7th)?
What day will you be leaving?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Section 2: Important information

The pharmacy will start FREE Medicare Open Enrollment reviews to any patients who need a stand-alone Medicare Part D Plan (PDP), October 15th - December 7th. Most reviews will be completed during the month of November.

Due to high demand for reviews this year we will ONLY contact you if our review identifies a reason you may want to consider a change. If you haven't heard from us by November 24th, please feel free to call us.
Should be Empty:

Medicare Open Enrollment