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RxCompare · Patient resource kit
Pharmacy quote worksheet
Ask each pharmacy for the exact same drug, strength, form, release type, quantity, and days supplied.
Full product name / strength / form: __________________________________
Quantity / days supplied confirmed by pharmacist: ______________________
| Detail to confirm | Pharmacy A | Pharmacy B |
|---|---|---|
| Pharmacy / phone | Space for handwritten notes | Space for handwritten notes |
| Quote date / valid until | Space for handwritten notes | Space for handwritten notes |
| Cash price | Space for handwritten notes | Space for handwritten notes |
| Insurance price | Space for handwritten notes | Space for handwritten notes |
| Discount price / eligibility | Space for handwritten notes | Space for handwritten notes |
| Delivery / other fees | Space for handwritten notes | Space for handwritten notes |
| Final total / days supplied | Space for handwritten notes | Space for handwritten notes |
| Availability / ready date | Space for handwritten notes | Space for handwritten notes |
| Deductible treatment confirmed with plan | Space for handwritten notes | Space for handwritten notes |
Before making a decision
- □ Confirm the final total, eligibility, and availability.
- □ Ask the insurer how an outside-plan purchase affects benefits.
- □ Confirm transfer and refill timing with the pharmacy.
- □ Keep medication and dose decisions with the care team.
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Cost worksheet, not medical advice or a medication administration record. Keep completed sheets private.