forms

For a review of your drug plan during Annual Enrollment

**PLEASE FILL OUT ALL FIELDS TO AVOID DELAY **

*Please do not list vitamins or over-the-counter medications
*If you take pills only “as needed” please put the average quantity you use per month
*If you use insulin, indicate how many pens or vials per month
*If you use a cream or gel, indicate how many tubes or bottles (and WHAT SIZE) per MONTH
*If you use inhalers, indicate how long one lasts
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