This application may be used for 2017 individual and family coverage through either Blue Cross Blue Shield of Michigan (BCBSM) or Blue Care Network of Michigan (BCN), depending on which medical plan you choose. Dental plans, dental with vision, and adult vision plans are only offered through BCBSM, but can be paired with BCBSM or BCN medical plans.
All fields are required to be completed unless otherwise noted. Review your application for completeness and accuracy and sign and date where requested. The information provided will be used and disclosed only as permitted by our Notice of Privacy Practices.
If you would like to apply for a subsidy or tax credit, if you are 30 or over and would like to check your eligibility for a hardship exemption to enroll in a Catastrophic (Value) Plan, or if you are Native American and are eligible for additional cost sharing benefits, please contact your Agent.
To get individual medical, dental, dental with vision, or adult vision coverage, you need to be a Michigan resident when your coverage starts. If you’re eligible for Medicare you can’t be eligible for individual medical coverage.