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Your San Diego area Customized Medicare Plan Request Form
Please provide your information and preferences below. Your customized Medicare Plan options will be generated in a few days. Click on Submit below when done.
First
*
Last
*
Date of Birth
*
Address
*
Email
*
City, State Zip
*
Phone
*
The Network I like or want to be in
*
Scripps Mercy
Scripps Clinic
Scripps Coastal
Sharp Community
Sharp Rees-Stealy
UCSD
ARCH
Tri-Cities
Primary Care Associated
Cassidy
Encompass
My Primary Care Physician
*
My Specialist(s)
*
I have enrolled in Medicare part A & B
*
Yes
No
Not Sure
I would like guidance with applying for Medicare Part A and B
*
Yes
No
I would like Free local Medicare Professional Help
*
Yes
No
My Preferred Pharmacy
*
Rite Aid
Vons
Mail Order
Costco
CVS
Walmart
Ralphs
Other
Medications
*
What health insurance do you currently have?
*
Original Medicare
Medicare Supplement Plan
Medicare Advantage Plan
A plan through the company I currently work for.
No insurance
Prefer not to say
Provide any additional Information or questions
*
I would like Customized Information on
*
Medicare Supplement PPO Plans
Medicare Advantage HMO Plans
Prescription Drug Plans
$0 Premium Plans
Medi-Cal Plans
Dental Plans
Companies I would like information on
*
United Health Care
SCAN
Humana
Aetna
Blue Shield
Care 1st
Blue Cross
Health Net
Unsure
I would like the following benefits if available
*
Acupuncture
Chiropractic
Hearing Aid discounts
Vision Services
Free Gym Membership
Transportation Service
Free Diabetes Supplies
Worldwide Urgent & Emergency Care
Submit
