Avail Insurance

Please complete the form below to request a review of your current plans' coverage of your

prescription drugs and provider network.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Customer Status

Are you a new or existing customer?

Plan Types

I am interested in the following plan types:

HMO

PPO

Medicare Supplements

Standalone Prescription Drug Plans

Provider Names (Name and Specialty)

Include names of Primary Care Doctor and any specialists you feel are important to your ongoing care. If there are doctors that you would be willing change, please make a note of that.

Current Prescriptions

If you would like for us to review your prescription costs and coverage, you have the option to list current Rx names, dosages and frequency.

Notes

Please list any notes you think are relevant to our research on your behalf.

Zip Code

benefits review

Please complete the form below to request a review of your current plans' coverage of your

prescription drugs and provider network.

Avail insurance