Medicare Agent Supply Order Form

Agent Supply Order Form

2027 supplies will not be available until the end of September. Any 2027 orders will not be processed.

If you are looking for Employer Group MAPD supplies, please place your order here.

If ordering non-group supplies, please continue with the form below.

1. Is this supply order for 2026 or 2027 materials? *This question is required.

2. First Name *This question is required.

3. Last Name *This question is required.

4. Email Address *This question is required. This question requires a valid email address.

5. Phone Number *This question is required.

Please note: we CANNOT make deliveries of supply orders to PO boxes.

6. Agency Name *This question is required.

7. Street Address - NO PO boxes *This question is required.

8. Suite #

9. City *This question is required.

10. State *This question is required.

11. Zip *This question is required. This question requires a valid number format.

12. Detail any specific delivery instructions below Note: this is for delivery instructions ONLY - please do not include additional requests pertaining to your order.

13. Are you are an Elite Agent? *This question is required.

14. Please enter your Elite Agent Number *This question is required.

14. How many MAPD plan pre-enrollment packets would you like? Max of 50.
(This packet includes PriorityMedicare, PriorityMedicare Edge, PriorityMedicare Key, PriorityMedicare Merit, PriorityMedicare Smart Savings, PriorityMedicare Value, PriorityMedicare Vintage, and PriorityMedicare Vital). This question requires a valid number format.

14. How many MAPD plan pre-enrollment packets would you like? Max of 25.
(This packet includes PriorityMedicare, PriorityMedicare Edge, PriorityMedicare Key, PriorityMedicare Merit, PriorityMedicare Smart Savings, PriorityMedicare Value, PriorityMedicare Vintage, and PriorityMedicare Vital). This question requires a valid number format.

14. How many Wellness plan pre-enrollment packets would you like? Max of 25.
(This packet includes PriorityMedicare Thrive and PriorityMedicare Thrive Plus). This question requires a valid number format.

14. How many Dual Eligible pre-enrollment packets would you like? Max of 10.
(This packet includes PriorityMedicare D-SNP and PriorityMedicare Dual Premier). This question requires a valid number format.

14. How many Medigap Pre-enrollment packets would you like? Max of 10. This question requires a valid number format.

14. How many Dental & Vision pre-enrollment packets would you like? Max of 5. This question requires a valid number format.