PLANS

COMMUNITY BLUE PPO HCTC-1
SIMPLE BLUE PPO HCTC-2
SIMPLY BLUE PPO HCA HCTC-3
3 PLANS CURRENTLY AVAILABLE
FOR IMMEDIATE ENROLLMENT
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ready to

enroll for 2021?

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ALL FOUR BENEFITS FOR ONE PRICE!

BUNDLED PLANS INCLUDE:

MEDICAL

PRESCRIPTION DRUG

DENTAL

VISION

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Call us today to help you enroll!! 1-844-428-2669

REQUIRED FORM THAT MUST BE COMPLETED FOR MICHIGAN STATE RESIDENTS ENROLLMENT
REQUIRED FORMS THAT MUST BE COMPLETED FOR HCTC ENROLLMENT

IT IS EXTREMELY IMPORTANT FOR THE FORMS TO BE FILLED OUT  PROPERLY AND COMPLETELY.

 

SEE SAMPLES BELOW FOR A GUIDE.

TO ENTER THE HCTC PROGRAM, you actually enroll in two programs.  The two programs you will enroll in are: 1.)  HCTC Program when you complete the 13441-A ENROLLMENT FORM (IRS/HCTC) AND

2.)  The Insurance Program when you complete the BCBSM ENROLLMENT FORM (BLUE CROSS BLUE SHIELD OF MICHIGAN).

YOU MUST ALSO PROVIDE a copy of your HCTC Eligible Supporting Documents (IRS form 1099R or paycheck stub)

SAMPLES OF FORMS THAT MUST BE COMPLETED FOR HCTC ENROLLMENT
(RETIREE ENROLLING)
(SINGLE PERSON ENROLLING)
(FAMILY ENROLLING)
(QUALIFIED FAMILY MEMBER ENROLLING)
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Call us 

      1 (800)  236-4782

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          the Forms?

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