Medicare Prescription Drug Form Please use this form to add all of your medications, in addition to any required fields. Name* First Last Email* Phone*Please add each of your medications Drug Name Dosage Actions Edit Delete There are no Drugs. Add Drug Maximum number of drugs reached. List any drugs you could not find, and their dosage.List preferred pharmacies.*Do you prefer mail order?*YesNoAgent EmailThis field is for validation purposes and should be left unchanged.