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Administrative Forms

New Blue Health Plans

(Blue Care, Blue Options, Blue Choice, Classic Blue, Dental Blue)
Enrollment / Change Form (1-24 employees) - ENROLL1 Tip Sheet Spanish Pre-existing Notice for Late Only Adds (For 51+ Groups Only)
Enrollment / Change Form (25+ employees) - ENROLL2 Tip Sheet Spanish Pre-existing Notice for Late and Subsequent Adds (For all Groups 25-50 and Most Groups 51+)
Decline of Coverage Form Pre-existing Notice for Late Only Adds (For 51+ Groups Only)
Adobe Acrobat Dental Claim Form Pre-existing Notice for Subsequent Only Adds (For 51+ Groups Only)
Spanish Enrollment Change Form (1-24 Employees) Pre-existing Notice for Late and Subsequent Only Adds (For all Groups 25-50 and most Groups 51+)
Spanish Enrollment Change Form (25+ Employees) Spanish Decline of Coverage Form
Spanish pre-existing Notice for Subsequent Only Adds (For 51+ Groups Only) Coverage Request for Mentally Retarded or Physically Handicapped Children
Health Savings Account (HSA) Payroll Deduction Form Student Leave of Absence Certification Form
Member Refusal to Provide SSN Affidavit Prior Approval Member Reminder Cards

Member Claim Form - Use this new, interactive form to complete your claims for medical, vision, and medical supplies expense reimbursement. You may enter your information directly on to the form, print it and mail it to us as usual. Tips for using the form:

  • Edits and calendars will help you enter accurate information.
  • When you click the new Print Form button on the claim, a message
    will be displayed if required information is missing.
  • Hover your mouse over the text fields for helpful information.
  • If you save the form to your PC, only the blank form will be saved, not the text you entered.
   

Medco Prescription Drug Claim Form - If your ID card has BNCDRUG in lower right front corner.

   

Mail-Order Prescription Form - get long-term medications by mail

   

Dental Plans

(Personal Care Plan, Medpoint, Preferred Care Select CoPay, Preferred Care Select, Preferred Care Costwise, Comprehensive Major Medical)
Adobe Acrobat Dental Blue Select Adminstrators Guide Dental Blue for Individuals Claim Form
Dental Blue Select Enhanced Employee Brochure Dental Blue for Groups Claim Form
Dental Blue Select Complete Employee brochure Handicap Form
Dental Blue Select Employee Standard Brochure Dental Blue Select Claim Form
Dental Blue Select Employer/Producer Brochure Dental Blue Select Employer Group Application
Dental Blue Select Employer Enrollment and Change Form    


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