Medicare Comparison Request Medicare Comparison Request For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.General InfoSelect Your StatePlease Note: We only write insurance for these states.SelectTexasName* First Last Phone*Email Address* Part B effective date: MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY Zip Code:Do you currently have Retiree Medical and/or Prescription Drug coverage (e.g., from a former employer or union)? Yes - If yes, you need to find out how current coverage will work with Medicare No What kind of Medicare coverage are you looking for? Check all that apply Medicare Advantage Plans - Prescription drugs are sometimes included Supplement/Gap Plan Prescription Drug coverage Not sure Coverage Needs: I live in a Nursing Home, LTC/Long Term Care Facility, or Assisted Living Facility I am eligible for Medicaid None of the above Coverage Preferences - Which do you prefer when budgeting for health care costs? Higher monthly premiums and lower out-of-pocket expenses Lower monthly premium and higher out-of-pocket expenses Which Medical Coverage do you prefer? A plan with few limitations regarding which hospital and doctors you can see A plan with a pre-approved list of doctors and hospitals Do you need local only coverage or national coverage? Local coverage - We don't travel much or have extended trips out of the local area National coverage - We travel and/or have extended stays and trips away from home Drug coverage I need prescription drug coverage I don't need prescription drug coverage Not sure Captcha