Supply Order Form Order 2022 Materials Order 2023 Materials Supply Order Form (2023) Please note: 2023 Materials will be shipped as they become 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:*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCarrier:Multiple carriers may be chosen. Miscellaneous ACE Medicare Supplement Aetna Aflac Medicare Supplement Blue Cross Blue Shield HealthPartners Humana Lumico/Elips Life Medicare Supplement 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. Or select from the materials listed below:H5216-273-000 Choice PPO H5216-067-000 NEW Choice PPO H5216-103-000 Choice PPO H5216-278-001 Choice PPO Honor Plan / No Drug H5216-354-000 NEW Choice PPO Honor Plan H5525-066 NEW Choice Honor Plan H5216-088-000 Choice PPO H5216-171-000 Choice PPO Value + H5216-092-000 Choice PPO H8145-089-000 Choice PFFS S5884-204-000 Walmart Value RX Plan - PDP S5884-145-000 Basic RX Plan - PDP S5884-171-000 Premier RX Plan - PDP H6622-073-000 Gold Plus HMO-POS Twin Cities H6622-062-000 Gold Plus HMO-POS Twin Cities H5216-275-000 Choice PPO Twin Cities H5216-303-000 Choice PPO Northern H5216-063-000 Choice PPO H5216-167-000 Choice PPO H5216-359-000 Choice PPO H5216-092-000 Choice PPO H5216-176-000 Choice PPO (Value Plus Plan) H5216-278-001 Choice PPO MA Only/No Drugs H5216-354-000 Choice PPO MA Only/No Drugs H8145-089-000 Gold Choice PFFS S5884-204-000 Walmart Value RX Plan - PDP S5884-145-000 Basic RX Plan - PDP S5884-171-000 Premier RX Plan - PDP Full Enrollment Forms (Humana) OSB Enrollment Forms (Humana) Envelopes for Mailing Enrollment Books (Humana) Scope of Appointment (Humana) 2023 Prime Solution Sales KitMN 2023 Advantage Solution Sales KitMN, Twin Cities, Metro 2023 Advantage Solution Sales KitMN, North 2023 Advantage Solution Sales KitMN, South Medicare Supplement Kits H7404-001-000 Twin Cities Med Adv Headwaters PPO H7404-002-000 Twin Cities Med Adv Lakeshore PPO H7404-004-000 MN LIS Med Advantage Premier PPO H7404-005-000 Northern MN Med Adv Headwaters PPO H7404-006-000 Northern MN Med Adv Lakeshore PPO H7404-011-000 Southern MN Med Adv Headwaters PPO H7404-012-000 Southern MN Med Adv Lakeshore PPO H7404-014-000 Twin Cities Med Adv Riverbank PPO H7404-015-000 MN MA Only Patriot PPO H7404-022-000 Northern Med Adv Riverbank (PPO) H7404-023-000 Southern MN Med Adv Riverbank (PPO) H3219-001 Plan Plus PPO H3219-002 Premier Plan PPO H3219-003 Grand PPO H3219-004 Elite PPO H3219-005 Eagle PPO Med Adv Core (MAPD)Metro, West, South Med Adv Comfort (MAPD)Metro, West Med Adv Choice (MAPD)Metro, West, South Med Adv Complete (MAPD)Metro, West, South Freedom Blue (MA-only)Metro, West, South PaceMetro/Central MN, Greater MN StrideMetro/Central MN, Greater MN DashMetro/Central MN, Greater MN SteadyMetro/Central MN, Greater MN SilverScript Smart RX SilverScript Choice RX SilverScript Plus RX Scope of Appointment (Generic) 2022 Choosing a Medigap Policy booklet (Generic)A Guide to Health Insurance for People with Medicare Medicare & You 2023 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!
