Hidden Form Field (Do Not Delete)
To start your submission, add your Agency's name below...
Agency Name
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Agency NPN
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Use "NA" if not applicable
Agency EIN
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First Name
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Last Name
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Mobile Phone
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Work Email
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Agent NPN Number
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Use "NA" if not applicable
Did a Lead Marketing Vendor create this material?
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Did a Lead Marketing Vendor create this material?
Yes
No
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If YES, Please Include Following Information Below...
Marketing Vendor Name
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Vendor Point of Contact
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Marketing Vendor Email
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Marketing Vendor Phone Number
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Marketing Vendor Address
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Type of Material:
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Marketing
Communication
Contract/Submission Type: This material includes or addresses any of the following content.
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Benefits - Document contains information about plan benefits.
Cost Share - Document contains information about beneficiary cost sharing. This could be C, D, or Optional Supplemental cost sharing.
PDM - For Part D Payment Modernization Model Content
PDSS - For Part D Senior Savings Model content
PDSS Other (non-R&I) - For marketing materials that contain Part D Senior Savings model information, excluding rewards and incentives (Please use the PDSS R&I for materials containing this content).
PDSS Updated Member Materials-CY2025 - A zipped file of all PDSS updated member materials per HPMS Memo "Updates to PDSS Model Communications and Marketing Guidelines for Contract Year 2025
Plan Comparisons - Document compares plan benefits/cost sharing/premiums/provider network/etc. to other plan(s). This could also include "generic" comparison such as "We have the lowest premium in the area." Any type of comparison must be noted.
Premiums - Document contains information about plan premiums. This could be C, D, or combined premiums. Could also be Optional Supplemental Premiums.
Provider Network - Document contains information about provider network.
Ranking Standards, other - Document provides all ranking standards (e.g. private company ratings) other than CMS' Star Ratings or Plan Comparisons identified in "Plan Comparisons" Content Type.
Rewards and Incentives - Document provides information about potential rewards and/or incentives for completion of plan identified health "activities."
SSBCI - Document provides information regarding Special Supplemental Benefits for the Chronically Ill (benefits, cost sharing, etc.)
Star Ratings - Document mentions CMS Star Ratings
VBID - Document provides information regarding Value-Based Insurance Design benefits, cost sharing, etc. For non marketing materials containing VBID content, please submit under "CMS Required"
Geography For Use: Is this campaign for a national audience?
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Yes
No
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Please select the states where this marketing will be seen:
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AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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Please provide all links to ANY Landing Pages, Sales Funnels related to your Paid advertising campaign below.
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Note: Please separate multiple URLs with a comma.
Line of Business
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MAPD
Medicare Supplement
Multiple
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Audience: Please Select the Intended Material Audience
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Current Members Only
Prospective Members Only
Current & Prospective Members
Material Life Cycle: Select the Material Life Cycle
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2025 Contract Year (10/1/24-9/30/25)
AEP Only (10/1-12/7)
2026 Contract Year (10/1/25-9/30/26)
Non-AEP Only (12/8/25-9/30/26)
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Intended Use Date:
Please select the Carriers your agency are contracted with below:
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Aetna
Cigna
Devoted
Elevance (Anthem)
Humana
Wellcare
UHC-United Health Care
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Are Carrier Logos Present in Your Submission?
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Yes
No
Carrier Logos: Select All That Apply
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Aetna
Cigna
Devoted
Anthem Brands
Humana, Inc
UHC
Wellcare
Other Regional (ex. Zing)
Is Co-Branding present in your submission?
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Yes
No
Add Material ID/SMID
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Provide all SMID's associated with the campaign/consumer experience. Separate multiple SMID's with a colon (:)
Material Description
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Please be specific and explain sales use case strategy and intent!
File Upload: Choose a File to Upload...
*Limit 10 files (Zip file is preferred for multiple files)
Attestation: Please Acknowledge Before Submitting:
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Based on my knowledge, information, and belief, I attest that the material is complete, accurate, and truthful. This attestation applies to all requirements under the File and Use Certification process and other CMS guidance.
Please attest that your agency and/or any vendors you're working with do not perform any TPMO functions outside of the United States.
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