Medicare Plan Review

Great news! Reviewing your plan and ensuring you're getting the most out of your coverage is always a good idea. We're here to help you navigate the changes and find the best options for your needs. Please fill out the form below with as much detail as possible so we can find the best coverage to fit your needs.

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What happens to my information?
Once you submit the information, we will receive an email with the data that will allow us to complete a comparison for you.
When complete, we will reach out to schedule a time to review your options. If you have any questions, please call 402-685-0588 or email GetStarted@NCIS5.com.

First Name

Please complete the submission per individual. If you have a spouse, submit their information after you have submitted yours.

Last Name

Birthday

Month

Day

Year

Phone

Prescription Medications

Include drug name and if generic include the generic name.

Include drug type, capsule, tablet, spray etc...

Include dosage - mg, mcg, etc...

Frequency - Number of pills per day.

Pharmacy

Please list your first and second choice pharmacy name and location.

Providers and Hospitals

Physician Name and Specialty (Internist, Cardiology, etc...)

Office Location (Address where you see the provider)

Include your preferred hospital should you need services.

Additional Notes

Include information you feel would be helpful in completing your evaluation.

Select your agent. If you select "none," one of our staff members will contact you.

Feel free to upload any additional information.

File upload

Submitting your information online you understand and agree to have your information provided to a licensed agent for future contact to discuss Medicare Advantage plans, Medicare Part D Prescription Drug plans, and /or Medicare Supplement insurance. By discussing plan options, you are not obligated to enroll in any plan and will not be automatically enrolled based on our discussion. Your future Medicare enrollment status will not be impacted by speaking with us about plan options.

The Centers for Medicare & Medicaid Services (CMS) requires agents to document the scope of a marketing appointment to ensure an understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative).

For compliance purposes, please verify that you would like the above-named agent to discuss Medicare plans, which may include:

Medicare Supplement Plans
Medicare Advantage Plans
Medicare Part D prescription drug plans

By discussing our plan options with an agent, you are not obligated to enroll in any plan and will not be automatically enrolled as a result of our discussion. Your future Medicare enrollment status will not be affected by speaking with the agent mentioned above about Medicare plan options.

By checking this box you agree to the above Scope of Appointment.