RX Comparison Request Form Please enable JavaScript in your browser to complete this form.Name *FirstLastZip Code *Phone *Email *Please list your prescriptions with the amount and how many times per dayIf you don't take any prescriptions, enter NONEPreferred PharmaciesWalmartWalgreensCVSLocal Grocery Store or PharmacyMail OrderLower Your Medicare Supplement Premiums-Provide the name of your current company, monthly premium and plan G, F or NSubmit