Agent Order Form

Please use this form to order enrollment materials for the Community CCRx and Today's Options Medicare Part D healthplans. If you have trouble with the form, please contact the pharmacy technical call center at (866) 684-5395 24 Hours a Day, 7 Days a Week.

Please note that some items have multiple versions, which vary by region. These items are shown under a heading for each state you choose below. Items which do not vary by region are included under the section called All Regions.

Please use this form to order enrollment materials for the Community CCRx and Today's Options powered by CCRx Part D healthplans. If you have trouble with the form, please contact the pharmacy technical call center at (866) 684-5395 24 Hours a Day, 7 Days a Week.

Please note that some items have multiple versions, which vary by region. These items are shown under a heading for each state you choose below. Items which do not vary by region are included under the section called All Regions.

Please note that most items will ship UPS Ground. After your order is shipped, you will receive an email with a tracking number. Generally, please allow 5-7 business days for your order to arrive. If you use a PO box to receive your materials, US Postal Service will be used and you will be unable to track your order.