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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 Brochures

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AIRLINE TRUST HCTC ENROLLMENT BOOK
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AUTO TRUST HCTC ENROLLMENT BOOK

SUMMARY PLAN DESCRIPTIONS

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SAMPLE 13441A Forms

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)

 

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CHANGING COVERAGE OPTIONS
NEW ENROLLMENTS
(QUALIFIED FAMILY MEMBER ENROLLING)

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(844)HCTC-NOW

(844)428.2669