Supply Order Form Order 2022 Materials Order 2023 Materials Supply Order Form (2022) Please note: Limited supplies 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 Lumico 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 PPO High ($98.00 plan premium) H5216-080-001 Choice PPO Metro Mid ($55.00 plan premium) H5216-080-002 Choice PPO Southern ($175.00 plan premium) H5216-080-003 Choice PPO Northern ($110.00 plan premium) H5216-092-000 Choice PPO Low Twin Cities ($38.00 plan premium) H5216-167-000 Choice PPO Mid ($78.00 plan premium) H5216-176-000 Choice PPO Value Plus ($33.50 plan premium) H5216-275-000 NEW Choice PPO Metro ($0.00 plan premium) H5216-278-001 Choice PPO MA Only ($0.00 plan premium) H5216-303-000 NEW Choice PPO Northern ($0.00 plan premium) H6622-062-000 Gold Plus HMO-POS Twin Cities ($128.00 plan premium) H6622-073-000 Gold Plus HMO-POS Twin Cities ($0.00 plan premium) H8145-089-000 Gold Choice PFFS ($96.00 plan premium) S5884-145-000 PDP Basic RX ($39.00 plan premium) S5884-171-000 PDP Premier RX ($72.60 plan premium) S5884-204-000 PDP Walmart Value RX ($22.20 plan premium) 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 H6154-002 HMO-POS Central MN ($0.00 plan premium)Medicare Advantage Solutions H8889-001 PPO Twin Cities ($85.00 plan premium)Medicare Advantage Solutions H8889-002 PPO Northern MN ($95.00 plan premium)Medicare Advantage Solutions H8889-003 PPO Twin Cities ($196.00 plan premium)Medicare Advantage Solutions H8889-004 PPO Southern MN ($125.00 plan premium)Medicare Advantage Solutions H8889-005 PPO Twin Cities ($45.00 plan premium)Medicare Advantage Solutions H8889-008 PPO Southern MN ($39.00 plan premium)Medicare Advantage Solutions H8889-009 PPO Minnesota ($0.00 plan premium)Medicare Advantage Solutions Prime Solution Kits Medicare Supplement Kits Basic - No Part B, Zone 1 Zip Codes 550-555 ($188.75)Basic Ext Basic - No Part B, Zone 1 Zip Codes 550-555 ($217.44)Extended Basic Basic, Zone 1 Zip Codes 550-555 ($205.25)Basic Ext Basic, Zone 1 Zip Codes 550-555 ($235.73)Extended Basic Basic - No Part B, Zone 2 Zip Codes 560+ ($170.77)Basic Ext Basic - No Part B, Zone 2 Zip Codes 560+ ($196.73)Extended Basic Basic, Zone 2 Zip Codes 560+ ($187.77)Basic Ext Basic, Zone 2 Zip Codes 560+ ($213.28)Extended Basic H7404-001-000 Twin Cities Medicare Adv Headwaters PPO ($0.00 plan premium) H7404-002-000 Twin Cities Medicare Adv Lakeshore PPO ($49.00 plan premium) H7404-004-000 Medicare Adv Premier PPO ($34.90 plan premium - varies by LIS level) H7404-005-000 Northern MN Medicare Adv Headwaters PPO ($0.00 plan premium) H7404-006-000 Northern MN Medicare Adv Lakeshore PPO ($58.00 plan premium) H7404-011-000 South MN Medicare Adv Headwaters PPO ($0.00 plan premium) H7404-012-000 Southern 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 MN MA Only Patriot PPO ($0.00 plan premium; Part B Rebate $30.00) H7404-022-000 Northern Medicare Adv Riverbank PPO ($99.00 plan premium) H7404-023-000 Southern MN Medicare Adv Riverbank PPO ($99.00 plan premium) 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 ($151.00 plan premium) H3219-005 Discover Value PPO ($0.00 plan premium) SilverScript Smart RX ($6.10) SilverScript Choice RX ($34.10) SilverScript Plus RX ($79.20) 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!
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