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The coverage you trust has a new name, but your current coverage will stay the same until you renew for 2016. 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 2015 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

Individual & Family Health Insurance Plan Change Form
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
myBlueAccess $2,500 paper enrollment application
myBlue Access $6350 Paper Enrollment Application
myBlue Access $1,500 Paper Enrollment Application
myBlue Access $3,000 Paper Enrollment Application
myBlue Access LP $4500 Paper Enrollment Application
myBlue Care Platinum $100 Paper Enrollment Application
myBlue Care Gold $5 00 Paper Enrollment Application
myBlue Care Silver $1
000 Paper Enrol lment Application
myBlue Multi State Plan $2000 Paper Enrollment Application
myBlue Multi State Plan $2500 Paper Enrollment Application
BlueCare Security Enrollment Application
CHIP Enrollment Application

Prescription Drug Forms

Approval Request Forms

Legal Forms

Auto Debit Service