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Enrollment Information

All the information you need to enroll a new group.

Checklist

Use this enrollment checklisticon-pdf to ensure all required information is submitted for processing.

Eligibility Guidelines

Review a summary of our enrollment standards, Membership at a

Glanceicon-pdf 

Order Enrollment Guides

Click here to order our 16-page, full-color enrollment guide, which introduces new clients and members to all of our medical, pharmacy and wellness programs.

 

Forms

Forms are in PDF icon-pdf format.

 Updated: 03/13/2013

Form Purpose
Average Employee Count Calculation Medical Loss Ratio employee count.
Group Enrollment Agreement To be signed and completed for coverage
Small Group Certification:
New Groups
To be completed for NEW small group enrollment (see below)
Small Group Certification: Requalifications To be completed for small group REQUALIFICATIONS
Small Group Certification: Transfers To be completed for small group TRANSFERS
Group Enrollment and Changes Used to enroll new members, change coverage, or cancel membership.
BlueCare Access Enrollment/Change Form  BlueCare Access Enrollment form for subscribers.
NOTE:  Use this form ONLY if you have BlueCare Access coverage.

 

Waiver of Group Health Insurance Benefits To be completed and signed ONLY if coverage is being waived.
2013 Enrollment Guide

Electronic version of our printed enrollment guides.

TEXT SIZE:  A A A

CalendarWithNote

The enrollment process typically takes 5-7 business days.

 

Enrollment is a first-in, first-out process.