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MBN LogoMedical Benefits NetworkMBN-USA · Est. 1989

Prescription Drug Plans

PDP Medicines Form

The same medicines sheet we mail to our customers. List what you take and we'll get it to your agent for your Part D plan review.

Instructions: Fill out your name and contact at the top. Then list your medicines, dosage, and frequency you are prescribed to take them.

Medicine NamePlease include the prescription name only. Please type in the generic name if you take the generic
Medicine Doseex. 5mg
Frequency You Take Itex. daily
Who is your agent? (mark one)
Gia F.Tom P.Julian P.Matt G.ScheduleOur team is online