Supply Order Form Order 2021 Materials Order 2022 Materials Supply Order Form (2021) Please note: Materials are shipped as they are made available.Date MM slash DD slash YYYY Agent Name:* First Last Agency: Agent Number: Phone*Address*NOTE: UPS will not send to a P.O. Box unless there is a street address. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Fax:Email:* Supplies Needed for State:*MinnesotaCarrier:Multiple carriers may be chosen. Miscellaneous Aetna Humana Medica UnitedHealthcare SilverScript Other Please note: UnitedHealthcare supply orders may be submitted through the www.uhcjarvis.com agent portal. Under Sales and Marketing Tools, go to the Sales Materials Portal, Order Materials.H5216-063-000 Choice High PPO ($106.00 plan premium) H5216-167-000 Choice Mid PPO ($88.00 plan premium) H5216-176-000 Choice Value +PPO ($28.80 plan premium) H5216-080-001 Choice Twin Cities - PPO ($58.00 plan premium) H5216-080-002 Choice Southern PPO ($173.00 plan premium) H5216-080-003 Choice Northern PPO ($108.00 plan premium) H5216-086-000 Honor PPO MA Only/No Drug ($0.00 plan premium) H5216-092-000 PPO - LOW ($37.00 plan premium) H6622-062-000 HMO-POS - TWIN CITIES ($126.00 plan premium) H6622-073-000 NEW Gold Plus HMO-POS - TWIN CITIES ($0.00 plan premium) H8145-089-000 PFFS - GOLD CHOICE ($94.00 plan premium) PDP - WALMART RX Plan PDP - WALMART Premier RX Plan PDP - WALMART Basic RX Plan Full Enrollment Forms (Humana) OSB Enrollment Forms (Humana) Envelopes for Mailing Enrollment Books (Humana) Scope of Appointment (Humana) H6154-001 HMO-POS Twin Cities ($0.00 plan premium)Medicare Advantage Solutions H8889-001 PPO Twin Cities ($105.00 plan premium)Medicare Advantage Solutions H8889-003 PPO Twin Cities ($199.00 plan premium)Medicare Advantage Solutions H8889-005 PPO Twin Cities ($49.00 plan premium)Medicare Advantage Solutions H6154-002 HMO-POS Gtr. Metro & Gtr. MN ($59.00 plan premium)Medicare Advantage Solutions H8889-002 PPO Gtr. Metro & Gtr. MN ($99.00 plan premium)Medicare Advantage Solutions H8889-004 PPO Southeast MN ($120.00 plan premium)Medicare Advantage Solutions Basic Base Rate TF ($175.10) | Standard ($203.80)Signature Solution Basic Total w/RIDERS TF ($235.70) | Standard ($271.00)Signature Solution Plan w/Part B Deductible TF ($244.00) | Standard ($280.60)Extended Basic Plan without Part B Deductible TF ($228.40) | Standard ($265.00)Extended Basic Plan N $20/50 Copayment TF ($194.30) | Standard ($223.40) Cost Plans: STANDARD ($0.00) | with RX ($30.90)Medicare Prime Solutions Cost Plans: THRIFT ($34.00) | with RX ($73.20)Medicare Prime Solutions Cost Plans: VALUE ($67.00) | with RX ($105.80)Medicare Prime Solutions Cost Plans: BASIC ($79.00) | with RX ($111.70) | with RX2 ($143.20)Medicare Prime Solutions Cost Plans: ENHANCED ($157.00) | with RX ($202.50) | with RX2 ($223.10)Medicare Prime Solutions H7404-001-000 Twin Cities Medicare Adv Headwaters PPO ($0.00 plan premium) H7404-002-000 Medicare Adv Lakeshore PPO ($49.00 plan premium) H7404-004-000 Medicare Adv Premier PPO (plan premium TBD - varies by LIS level) H7404-005-000 North MN Medicare Adv Headwaters PPO ($0.00 plan premium) H7404-006-000 North MN Medicare Adv Lakeshore PPO ($58.00 plan premium) H7404-011-000 South MN Medicare Adv Headwaters PPO ($19.00 plan premium) H7404-012-000 South MN Medicare Adv Lakeshore PPO ($49.00 plan premium) H7404-014-000 Twin Cities Medicare Adv Riverbank PPO ($99.00 plan premium) H7404-015-000 Medicare Adv Patriot PPO ($0.00 plan premium; Part B Rebate $25.00) H3219-001 Discover Plus PPO ($0.00 plan premium) H3219-002 Discover Premier PPO ($46.00 plan premium) H3219-003 Discover Grand PPO ($96.00 plan premium) H3219-004 Discover Elite PPO ($146.00 plan premium) H3219-005 Discover Value PPO ($0.00 plan premium) SilverScript Smart RX ($7.38) SilverScript Choice RX ($28.92) SilverScript Plus RX ($68.79) Scope of Appointment (Generic) 2021 Choosing a Medigap Policy booklet (Generic)A Guide to Health Insurance for People with Medicare Medicare & You 2022 booklet (Generic)The official U.S. Government Medicare handbook Notes:Please provide any additional notes below that will help us fill your request:Don’t forget about our Next Day Supply Fulfillment services!
