Over 65 Materials Order Form

Please complete this form to order Over 65 MedPlus supplies, including individual dental, vision and/or Medicare Advantage supplies.

*Required

Contact/Addressee*

Agency Name*

Street Address—P.O. Boxes NOT acceptable*

City*

State*

Zip*

Phone* (format: xxx-xxx-xxxx)

Email*

Enter the quantity for each of the items you’d like to order.

MedPlus, Dental and Vision

2023 Maryland MedPlus—Baltimore Metro

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2023 Maryland MedPlus—Eastern & Southern Area

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2023 Maryland MedPlus—D.C. Metro

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2023 Maryland MedPlus—Western Area

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2023 Washington, D.C. MedPlus

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2023 Virginia MedPlus

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Dental Coverage - Individual Select Preferred & Individual Select Preferred Plus, MD/DC/VA (DPP)**

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Dental Coverage - 2023 BlueDental Preferred, MD/DC/VA (DBP)**

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Vision Coverage - BlueVision, MD/DC/VA (BVI)

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**Contains three applications; one per jurisdiction

Medicare Advantage

2023 Maryland Medicare Advantage Pre-Sales Book Service Area 1 (Anne Arundel, Carroll, Frederick, Harford, Howard) (M23-1)

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2023 Maryland Medicare Advantage Pre-Sales Book Service Area 2 (Baltimore City, Baltimore, Montgomery, Prince George’s) (M23-2)

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Educational Brochures (No applications within)

Medicare Made Simple Guide (GMED)

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Please complete all required fields and submit.