Medicare Rx Drug Coverage Counseling Tool

Instructions: In order to provide accurate results, it is important that you answer every question. Give the complete name of each medication, including any suffixes, such as Hcl, ER, HFA, etc. Indicate whether drug is a capsule, tablet, ointment, etc. The Benefits Assistance Program, part of the AZ SHIP program, does not recommend or endorse any particular drug plan or company and is not responsible for the service provided by these companies.
  • Please enter the SHIP Counselor who is assisting you.
  • Medicare Card
  • Name of Medication (example: Metformin Hcl)Form of Medication (Tablet, Capsule, etc.)Strength (10 mg)Daily Dosage 
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    Results will be completed and given to you within five (5) business days or less. Information will be limited to only the top three (3) Drug Plans of Health Plans that meet your specific needs.
  • This field is for validation purposes and should be left unchanged.