FORMS

PRE 65 Brochures, Enrollment Information & Forms

HCTC Forms

If enrolling in the HCTC (Health Coverage Tax Credit) you will need to complete TWO forms (13441A Form - IRS Enrollment Form and the HCTC Trust Enrollment Form. There are sample forms for the 13441A forms below, to assist you in completing the form correctly. The 13441A form is required by the IRS/HCTC Program to receive the 72/5% subsidy.

HCTC AIRLINE ENROLLMENT FORM

13441A Form - IRS Enrollment Form

HCTC AUTO ENROLLMENT FORM

13441A Form - IRS Enrollment Form

HCTC STEEL ENROLLMENT FORM

13441A Form - IRS Enrollment Form

HCTC Brochures

AIRLINE TRUST HCTC ENROLLMENT BOOK

AUTO TRUST HCTC ENROLLMENT BOOK

SUMMARY PLAN DESCRIPTIONS

GOLD PLAN SPD

SILVER PLAN SPD

STEEL TRUST HCTC ENROLLMENT BOOK

BRONZE PLAN SPD

SAMPLE 13441A Forms

SAMPLE for New Enrollment

SAMPLE for Qualified Family Member

SAMPLE for Changing Coverage

POST 65 Brochures, Enrollment Information & Forms

Medicare Forms

1.) Please review the Formulary provided below.

2.) The BCBSM Medicare Advantage Plans INCLUDE a Prescription Drug Plan. Please review the Benefit at a Glance Document for all 3 plans to determine what fits your needs if you are interested in a Medicare Advantage Plan.

3.) The Hartford Supplemental Plans can be elected with a BCBSM High or Low Prescription Drug Plan.

4.) You can enroll in one of the Standalone Prescription Drug Plans that are offered through BCBSM. (You are not allowed to enroll in the standalone Prescription Drug Plan if you are enrolled in a different Medicare Advantage Plan)

MEDICARE AIRLINE ENROLLMENT FORM

Enrollment Book