Maximize Your Medicare Coverage

Thank you for your interest in our new Medicare Savings Program! Our goal is to provide you with information that helps you save even more money while improving your coverage through the Medicare Part D program.

To help us optimize your current Medicare Part D plan, please fill out the form below. Please include all information on the medications you are currently taking.

* Required Fields

** Please enter a phone number and/or an email address. Only one is required.

Customer Name *
Phone Number **
Email Address **
Name of Part D Insurance Provider
State & Zip Code *
Month you reach the Coverage Gap *
What is the Coverage Gap?

Also known as the "Donut hole" This is where your initial medication coverage stops and you start paying 100% out of pocket for your prescriptions until you reach catastrophic coverage. In 2009 this gap occurs between $2,700-$6,154.
Annual Deductible * $
Annual Deductible

If your plan does not have an Annual Deductible please enter $"0.00".
Monthly Premium * $
Monthly Premium

Your monthly payment to your private health insurance plan for Medicare Part D coverage. eg. $"25.00"

*** Please be sure to include at least one medication.

Medication Name Strength Pills per day Co-pay Medicare Covers Do you take generics?
Co-pay
Please enter your Co-pay dollar amount or percentage. eg. "$25" or "$25.00" or "25%"
Medicare Coverage
Please enter your plan's Medicare coverage dollar amount. eg. $"5" or $"5.00"
Do you take generics?
Please select this check box if you are currently taking a generic version of the specified medication.
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Additional Comments
Word Verification *

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Be advised that, given the international nature of the practice of International Prescription Services (IPS) pharmacy, there may be limitations in the ability of the Manitoba Pharmaceutical Association (MPhA), which is the statutory licensing authority for pharmacies and pharmacists in the Province of Manitoba, to investigate and prosecute complaints from persons who receive services or products from an IPS pharmacy.

Manitoba pharmacists are not permitted to fill US physicians' prescriptions. They can only fill prescriptions issued by a physician licensed in a province or territory of Canada. M.Ph.A takes the position that it may be contrary to professional standards for a pharmacist to fill prescriptions by a physician, licensed in a province or territory of Canada, who has not established an acceptable patient physician relationship with you.

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CanadaDrugs.com LP is presently licensed in the province of Manitoba by the Manitoba
Pharmaceutical Association. License Number 32195

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