Indicate the materials you want to order by completing the "quantity" field. You can search by form name or number by using Ctrl + F.
Proceed to the bottom of the form to enter the required information in the fields below.
If you experience problems with this form, or have questions about your order, please send an e-mail message to PRODSPT@NebraskaBlue.com.
BCBSNE will not send the following Medicare Advantage and/or MedicareBlue Rx marketing materials to agents who are not certified to sell Medicare products. Please check the box below to verify you have completed both the AHIP training and the product training to become Medicare certified.
I verify that I am currently certified to sell Medicare Advantage and/or MedicareBlue Rx products. I understand that selling Medicare Advantage and/or MedicareBlue Rx products without being certified can result in loss of my sales appointment.
To ensure timely processing, Medicare Advantage orders will be capped at 50 kits.
Can't find a form? Please provide form number:
Nondiscrimination Notices and Language must be provided with each document that requires a signature from the qualified individual, applicant or enrollee.