PLANS

COMMUNITY BLUE PPO HCTC-1

SIMPLE BLUE PPO HCTC-2

SIMPLY BLUE PPO HCA HCTC-3

3 PLANS CURRENTLY AVAILABLE

FOR IMMEDIATE ENROLLMENT

ready to

enroll for 2021?

ALL FOUR BENEFITS FOR ONE PRICE!

BUNDLED PLANS INCLUDE:

MEDICAL

PRESCRIPTION DRUG

DENTAL

VISION

SUMMARY OF BENEFITS - PPO Community Blue Plan

SUMMARY OF BENEFITS - PPO Simple Blue Plan

SUMMARY OF BENEFITS - PPO Simply Blue Plan

BCBS Form - Medical Enrollment Form

SUMMARY OF BENEFITS - PPO Community Blue Plan

BCBS Form - Medical Enrollment Form

SUMMARY OF BENEFITS - PPO Simple Blue Plan

BCBS Form - Medical Enrollment Form

SUMMARY OF BENEFITS - PPO Simply Blue Plan

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

REQUIRED FORM THAT MUST BE COMPLETED FOR MICHIGAN STATE RESIDENTS ENROLLMENT

BCBS Form - Medical Enrollment Form

BCBSM Enrollment Form

REQUIRED FORMS THAT MUST BE COMPLETED FOR HCTC ENROLLMENT

13441-A (IRS) Enrollment Form

BCBSM Enrollment Form

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)

(QUALIFIED FAMILY MEMBER ENROLLING)

STATE QUALIFIED PLANS

MICHIGAN STATE RESIDENTS

HEALTH COVERAGE TAX CREDIT (HCTC)

Call Center

1(800) 236-4782

Providing the best insurance coverage for the residents of the State of Michigan and specialize in assisting Michigan HCTC Qualified Members and their dependents.

MEDICAL, PRESCRIPTION DRUG, DENTAL & VISION BUNDLED PPO PLANS

PLANS

COMMUNITY BLUE PPO HCTC-1

SIMPLE BLUE PPO HCTC-2

SIMPLY BLUE PPO HCA HCTC-3

3 PLANS CURRENTLY AVAILABLE

FOR IMMEDIATE ENROLLMENT

ALL FOUR BENEFITS FOR ONE PRICE!

BUNDLED PLANS INCLUDE:

MEDICAL

PRESCRIPTION DRUG

DENTAL

VISION

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

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)

Call us

1 (800) 236-4782

Need Help

Completing

the Forms?

Just

have

Questions?

Or

Call Center

1(800) 236-4782

PLANS

COMMUNITY BLUE PPO HCTC-1

SIMPLE BLUE PPO HCTC-2

SIMPLY BLUE PPO HCA HCTC-3

3 PLANS CURRENTLY AVAILABLE

FOR IMMEDIATE ENROLLMENT

ALL FOUR BENEFITS FOR ONE PRICE!

​

BUNDLED PLANS INCLUDE:

MEDICAL

PRESCRIPTION DRUG

DENTAL

VISION

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

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)

Call us

1 (800) 236-4782

Need Help

Completing

the Forms?

Just

have

Questions?

Or