Self-Service Login / Register | bluecrossnepastore.com
Powered by Google
Open Enrollment Ended March 31st. If you have a qualifying life event, you may still be able to buy coverage for 2014. Call us today at 1.866.514.2454. Learn More

Member Forms

Adjust type sizesmallmediumlarge

From time to time you may need to complete a form to get the most from your health insurance.  For example, if you need a specialty drug approved or need to file a claim for vision services.  Or maybe you need to add a disabled dependent to your coverage. When you need it, you’ll find it right here.

If you have health insurance through your employer, be sure to select “Group Health Plan Forms” from the list below.  Or select “Individual Health Plan Forms” if you are enrolled in one of our direct-pay individual health insurance plans.


Enrollment Applications

2014 Special Enrollment Form (FP-1-I-APP-SEFM)
Individual & Family Health Insurance Plan Change Form (FP-1-I-APP-CHGFM)
myBlue Choice $250 Paper Enrollment Application
myBlue Choice $1000 Paper Enrollment Application
myBlue Choice $2500 Paper Enrollment Application
myBlue Choice LP $5500 Paper Enrollment Application
myBlue Access $500 Paper Enrollment Application
myBlue Access $750 Paper Enrollment Application
myBlue Access $1500 Paper Enrollment Application
myBlue Access $6350 Paper Enrollment Application
myBlue Access LP $4500 Paper Enrollment Application
myBlue Care $1000 Paper Enrollment Application
myBlue Multi State Plan $2000 Paper Enrollment Application
myBlue Multi State Plan $2500 Paper Enrollment Application
BlueCare Direct Enrollment Application/Change Form (PD-40006)
BlueCare Direct Advantage Enrollment Application/Change Form
BlueCare Direct Essentials Enrollment Application/Change Form
BlueCare Direct Select Enrollment Application/Change Form
BlueCare Security Enrollment Application (03-B0040)
Special Care Enrollment Application (05-B00066)
CHIP Enrollment Application (01-F0644)

Prescription Drug Forms

Approval Request Forms

Legal Forms

Auto Debit Service

Vision Forms

Vision benefit administration is provided by an independent and/or separate company that does not provide Blue Cross® products and/or services.

Vision Claim Form