Supply Order Form Order 2023 Materials Order 2024 Materials Supply Order Form (2024) Please note: 2024 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. Aetna (MN) SilverScript Blue Cross Blue Shield (MN) HealthPartners (MN) HealthPartners (WI) HealthPartners (ND/SD) Humana (MN) Humana (ND) Medica (MN) Medica (ND/SD) Medica (WI) UnitedHealthcare (MN) Miscellaneous 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:H5216-088-000 Choice PPO H5216-092-000 Choice PPO H5216-171-000 Choice PPO H5216-273-000 Choice PPO H5216-278-001 USAA Honor PPO MA Only/No Drug H5216-354-000 USAA Honor PPO MA Only/No Drug H5216-398-000 NEW Choice PPO H5525-067-000 Choice PPO S5884-204-000 Walmart Value RX Plan - PDP S5884-145-000 Basic RX Plan - PDP H8145-089-000 Choice PFFS S5884-171-000 Premier RX Plan - PDP H5216-278-001 USAA Honor PPO MA Only / No Drug H5216-354-000 USAA Honor PPO MA Only / No Drug H5216-359-000 Choice PPO H5216-397-000 NEW Choice PPO 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 H8145-006-000 Gold Choice PFFS Allina Health MAPD Kit RX Kit Medicare Advantage PPO (Metro, West, South) Platinum Blue Medicare Supplement MedicareBlueRX Journey MAPD (Metro/Central) Journey MAPD (Greater MN) Freedom Cost Plans (Western WI) Robin Medicare Advantage (Northeastern WI) Freedom Cost Plans Freedom Cost Plans Prime Solution Sales Kit MN Advantage Solution Sales Kit MN, Twin Cities, Metro Advantage Solution Sales Kit MN North Advantage Solution Sales Kit MN South Prime Solution Sales Kit Prime Solution Sales Kit Advantage Solution Sales Kit Advantage Solution Sales Kit Prime Solution Sales Kit H7404-001-000 Twin Cities Med Advantage Headwaters PPO H7404-002-000 Twin Cities Med Advantage Lakeshore PPO H7404-004-000 MN LIS Med Advantage Premier PPO H7404-005-000 Northern MN Med Advantage Headwaters PPO H7404-006-000 Northern MN Med Advantage Lakeshore PPO H7404-011-000 Southern MN Med Advantage Headwaters PPO H7404-012-000 Southern MN Med Advantage Lakeshore PPO H7404-014-000 Twin Cities MN Med Advantage Riverbank PPO H7404-015-000 MN MA Only Patriot PPO H7404-022-000 Northern MN Med Advantage Riverbank PPO H7404-023-000 Southern MN Med Advantage Riverbank PPO OSB Enrollment Forms (Humana) Envelopes for Mailing Enrollment Books (Humana) Scope of Appointment (Humana) Scope of Appointment (Generic) 2023 Choosing a Medigap Policy booklet (Generic)A Guide to Health Insurance for People with Medicare Medicare & You 2024 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!