Drug Lookup Form

Rx Drug Lookup Form

Free Text

Complete the below form and someone from our office will contact you as soon as possible.

Full Name*

Email*

Phone*

ZIP Code*

What Is Your Preferred Pharmacy?

Are You Open to Having Your Prescriptions Mailed to You, if It Saves You Additional Money?*

Yes

Which Insurance Producer Would You Like to Work With?

Medication 1

Drug Name

Dosage?

Times Per Day

Medication 2

Drug Name

Dosage?

Times Per Day

Medication 3

Drug Name

Dosage?

Times Per Day

Medication 4

Drug Name

Dosage?

Times Per Day

Medication 5

Drug Name

Dosage?

Times Per Day

Medication 6

Drug Name

Dosage?

Times Per Day

Medication 7

Drug Name

Dosage?

Times Per Day

Medication 8

Drug Name

Dosage?

Times Per Day

Medication 9

Drug Name

Dosage?

Times Per Day

Medication 10

Drug Name

Dosage?

Times Per Day

Provider 1

Full Name

Specialty

City

ZIP Code

Provider 2

Full Name

Specialty

City

ZIP Code

Provider 3

Full Name

Specialty

City

ZIP Code

Provider 4

Full Name

Specialty

City

ZIP Code

Provider 5

Full Name

Specialty

City

ZIP Code

Comments / Additional Drugs or Doctors*

Get in Touch

Thank you for reaching out. By filling out the form below a sales agent may mail, call, or e-mail as a result of completing the information to discuss Medicare Advantage, Prescription Drug Plans or Medicare Supplement Insurance. We look forward to speaking with you soon!

Phone:
(509) 435-2120

Email:
sharonlewis@lifelineprotection.com

1028 W Rosewood Ave, Spokane, WA 99208, United States of America

Hours of Operation

Available by appointment.

Connect With Us

Disclaimer: “Medicare has neither reviewed, nor endorsed this information.” We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, Your State Health Insurance Program (SHIP), or call 1-800-MEDICARE to get information on all of your options.