What You'll Need
Medicare Supplement with PDP
Before You Begin
To make your Medicare Supplement with PDP application as quick & easy as possible, please have the following information ready.
Personal Information
- Full Name
- Current Address
- County
- Phone Number
- Email Address (if applicable)
Medicare Information
- Medicare Card
- Medicare ID Number
- Medicare Part A Effective Date
- Medicare Part B Effective Date
Don't have your Medicare card? No problem. You can provide your Social Security Number & Date of Birth instead.
Prescription Medications
- Medication Names
- Dosages
- Medication Type (Tablet, Capsule, Liquid, or Other)
- How Often You Take Each Medication
Eligibility Information
- Marital Status
- Veteran Status
- Retiree or Spouse Coverage
- Medicaid Coverage (including Medicaid ID if applicable)
Rehabilitation Facility Information (if applicable)
- Facility Name
- Address
- Phone Number
- Admission Date
Medicare Supplement Enrollment Information
- Social Security Number
- Bank Name
- Routing Number
- Account Number
- Preferred Monthly Withdrawal Date
Some items above only apply to certain individuals. If a section doesn't apply to you, you can simply skip it during the application.
Your progress is automatically saved on this device — you can return later to finish.