Part D Information – Medicare Now Colorado

Name*
First Last
ZIP Code*
Your Favorite Pharmacy
Another Pharmacy for Backup
Any pharmacy you won't use?
I need your new Medicare ID number!*
Your Medicare ID is 11 characters and numbers. It should not include your Social Security number! (The government changed this.)
Drugs You're Taking
Drug Name
Drug Dosage
How Often is Drug Taken?
Maximum of 12 drugs