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State of Iowa

info@iowa.gov

200 E Walnut, Des Moines , IA, 50309, US

SHIIP-SMP Logo

2020 Open Enrollment Period Request for Comparison

I understand by completing this form and submitting my information to the SHIIP-SMP Program my information will be kept confidential. I also give the SHIIP-SMP Staff and Counselor permission to contact me about the comparison.

You have selected No - you do not give SHIIP-SMP permission to complete a comparison for you.  Please exit this form.  Thank you for your interest in the SHIIP-SMP Program.

Name

Mailing Address

What is your Part A effective date?

What is your Part B effective date?

Do you have a Medicare.gov account?

What is your Date of Birth?

What is your gender?

Primary Language

Is your income above the following amounts? Individual--$19,380/yr ($1,615/mo) or Couple--$26,100/yr ($2,175/mo)

Are your assets above the following amounts: Individual--$14,610 or Couple--$29,160?

Are you on Medicare due to a disability (under age 65)?

Ethnicity/Race: Please select one of the following:

How did you hear about SHIIP-SMP?

What is your current drug coverage? Check any that apply.

How would you like to get your Medicare drug benefits? Please provide a comparison of (check one):

Do you currently receive any of the following benefits?

Pharmacy #1 Address

Pharmacy #2 Address

List your prescriptions drugs so that a comparison can be completed.  Please be sure to include dosage, frequency and generic or brand in the appropriate area. For any inhalers or injections please also provide package size (i.e. 1 inhaler, 6 pens per package, etc.)

Once you have entered all your drugs please click submit and your information will be submitted via a secure document to SHIIP.

1.A. Drug Form

1.B. Generic or Brand

2.A. Drug Form

2.B. Generic or Brand

3.A. Drug Form

3.B. Generic or Brand

4.A. Drug Form

4.B. Generic or Brand

5.A. Drug Form

5.B. Generic or Brand

Do you need to add more drugs to your drug list?

6.A. Drug Form

6.B. Generic or Brand

7.A. Drug Form

7.B. Generic or Brand

8.A. Drug Form

8.B. Generic or Brand

9.A. Drug Form

9.B. Generic or Brand

10.A. Drug Form

10.B. Generic or Brand

2. Do you need to add more drugs to your drug list?

11.A. Drug Form

11.B. Generic or Brand

12.A. Drug Form

12.B. Generic or Brand

13.A. Drug Form

13.B. Generic or Brand

14.A. Drug Form

14.B. Generic or Brand

15.A. Drug Form

15.B. Generic or Brand

3. Do you need to add more drugs to your drug list?

16.A. Drug Form

16.B. Generic or Brand

17.A. Drug Form

17.B. Generic or Brand

18.A. Drug Form

18.B. Generic or Brand

19.A. Drug Form

19.B. Generic or Brand

20.A. Drug Form

20.B. Generic or Brand

4. Do you need to add more drugs to your drug list?

21.A. Drug Form

21.B. Generic or Brand

22.A. Drug Form

22.B. Generic or Brand

23.A. Drug Form

23.B. Generic or Brand

24.A. Drug Form

24.B. Generic or Brand

25.A. Drug Form

25.B. Generic or Brand