PDP Helper – Northwest Senior Insurance

Welcome to the PDP Helper page for Northwest Senior Insurance!

Please follow the instructions below to submit a list of your prescriptions to us so we can help you select a Prescription Drug Plan for the next year.

If you would like some additional guidance on how to use PDP Helper, please check out our PDPHelper Tips article.

- Step 1 of 4

Contact Information

Please enter in your contact information so we will be able to get in touch with you.

Name *

First

Last

Phone *

Not required, but highly recommended so we have an alternate means of communication.

Zip Code

County

Pharmacy Information

Please enter your pharmacy of choice and, if applicable, any alternate pharmacies you might consider using. Then answer the following two questions.

Pharmacy Of Choice *

Alternate Pharmacy 1

Alternate Pharmacy 2

Would you be willing to use one of these pharmacies if it will save you money? (Select all that apply)

Walmart
Walgreens
Mail Order

Some plans offer substantially lower copays with specific retail pharmacies or mail order.

List your pill, capsule and tablet prescriptions here

On this page please enter only prescription pills, tablets, and capsules. Other prescriptions like Insulin, inhalers, eye drops, topical creams and more can be entered on the following two pages.

Important: If you take something on an “as needed” basis, please estimate how many you use per 1, 2, 3 or 12 Month(s) and fill that in instead. For us to shop your meds on Medicare.gov we need hard numbers.

Name of Prescription (1)

Dosage

Quantity

Frequency (Select One)

Name of Prescription (2)

Dosage

Quantity

Frequency (Select One)

Name of Prescription (3)

Dosage

Quantity

Frequency (Select One)

Name of Prescription (4)

Dosage

Quantity

Frequency (Select One)

Add more pill, capsule, or tablet prescriptions?

Name of Prescription (5)

Dosage

Quantity

Frequency (Select One)

Name of Prescription (6)

Dosage

Quantity

Frequency (Select One)

Add more pill, capsule, or tablet prescriptions?

Name of Prescription (7)

Dosage

Quantity

Frequency (Select One)

Name of Prescription (8)

Dosage

Quantity

Frequency (Select One)

Name of Prescription (9)

Dosage

Quantity

Frequency (Select One)

Add more pill, capsule, or tablet prescriptions?

Name of Prescription (10)

Dosage

Quantity

Frequency (Select One)

Name of Prescription (11)

Dosage

Quantity

Frequency (Select One)

Name of Prescription (12)

Dosage

Quantity

Frequency (Select One)

Insulin, Inhalers and Nebulizer

Do you use insulin?

Important: We need to know approximately how many insulin vials or pens you buy every 1, 2, 3, or 12 months. This is what Medicare.gov requires and anything else will result in delays as we will need to call you to clarify before we can proceed.

Click to show examples

**Example Insulin Entries**
Name of Insulin (Example 1)
Humalog
Vial or Pen?	Size	Quantity	Frequency
Vial	10 mL	1	per Month

Name of Insulin (Example 2)
Lantis Solostar
Vial or Pen?	Size	Quantity	Frequency
Pen	3 mL	5	per 2 Month

Name of Insulin (1)

Vial or Pen?

Size

Quantity

Frequency

Name of Insulin (2)

Vial or Pen?

Size

Quantity

Frequency

Name of Insulin (3)

Vial or Pen?

Size

Quantity

Frequency

Name of Insulin (4)

Vial or Pen?

Size

Quantity

Frequency

Do you use any inhalers or nebulizers?

Important: We need to know approximately how many inhalers or nebulizers you buy every 1, 2, 3, or 12 months. This is what Medicare.gov requires and anything else will result in delays as we will need to call you to clarify before we can proceed.

Click to show examples

**Example Inhaler Entries**
Name of Inhaler (Example 1)
Ventolin HFA
Size	Quantity	Frequency
18 gm	1	per Month

Name of Inhaler (Example 2)
Albuterol Sulfate NEB 0.5%
Size	Quantity	Frequency
3 mL	30	per Month

Name of Inhaler (1)

Size

Quantity

Frequency

Name of Inhaler (2)

Size

Quantity

Frequency

Name of Inhaler (3)

Size

Quantity

Frequency

Name of Inhaler (4)

Size

Quantity

Frequency

Eye Drops. Gels, Creams, Lotions or Salves, and Other Prescriptions

Do you use eye drops?

Important: We need to know approximately how many eye drop bottles you buy every 1, 2, 3, or 12 months. This is what Medicare.gov requires and anything else will result in delays as we will need to call you to clarify before we can proceed.

Click to show examples

**Example Eye Drop Entries**
Name of Eye Drop (Example 1)
Latanoprost SOL 0.005%
Size	Quantity	Frequency
2.5 mL	1	per Month

Name of Eye Drop (Example 2)
Bepreve DRO 1.5%
Size	Quantity	Frequency
5 mL	1	per Month

Name of Eye Drop (1)

Bottle Size

Quantity

Frequency

Name of Eye Drop (2)

Bottle Size

Quantity

Frequency

Name of Eye Drop (3)

Bottle Size

Quantity

Frequency

Name of Eye Drop (4)

Bottle Size

Quantity

Frequency

Do you use any gels, creams, lotions or salves?

Important: In order for us to estimate your prescription costs on Medicare.gov, we need to know how many tubes or bottles you buy every 1, 2, 3, or 12 months. Anything else will result in delays as we will need to call you to clarify before we can proceed.

Click to show examples

**Example Gel, Cream, Lotion or Salve Entries**
Name of Gel, Cream, Lotion or Salve (Example 1)
Fluticasone Propionate Topical CRE 0.05%
Size	Quantity	Frequency
30 gm tube	1	per 2 Months

Name of Gel, Cream, Lotion or Salve (Example 2)
Estrace CRE 0.1mg/gm
Size	Quantity	Frequency
42.5 gm tube	1	per 3 Months

Name of Gel, Cream, Lotion or Salve (1)

Size

Quantity

Frequency

Name of Gel, Cream, Lotion or Salve (2)

Size

Quantity

Frequency

Name of Gel, Cream, Lotion or Salve (3)

Size

Quantity

Frequency

Name of Gel, Cream, Lotion or Salve (4)

Size

Quantity

Frequency

Do you have other prescriptions to enter (Powders, Suspensions, Solutions, Injectables, etc.)?

In the text box below please use the format: Name, Size, Quantity, Frequency

Important:For frequency, we need to know how many you buy every 1, 2, 3, or 12 months in order to provide an estimate on Medicare.gov.

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