Medical Insurance Forms

All of forms on this website are in PDF format. If you do not have Adobe Reader, download from www.adobe.com. Click on the form you want and print or save it to your computer.

Blue Cross/Blue Shield Website

PPO	HMO
Highlights - 2011	Highlights - 2011
Highlights - 2012	Highlights - 2012
Policy Booklet	Policy Booklet
Enrollment/Change	Enrollment/Change

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We offer two different medical plans to choose from – PPO and HMO; both plans are with BlueCross/BlueShield. There is no waiting period for coverage; you are eligible on your first date of employment. If you want medical insurance, choose which plan you would like, fill out the appropriate enrollment form and return it to me within 30 days from your start date.

Highlights/Policy Books – These will give you more details as to the benefits of each type of plan. You can use this to help you decide which plan is right for your situation.

BCBS PPO

Enrollment form – Please complete Part 4 – 8 of the form as appropriate and sign Part 10.

(PPO) Finding a Doctor – The best way to find a doctor in the network is to look on the BlueCross BlueShield website at www.bcbsil.com, call them at (800) 806-7612, or ask your doctor if s/he is in the BlueCross PPO network. It is always best to double check with your doctor that s/he is still part of the network.

BCBS HMO Illinois

Enrollment form – Please complete Part 4 – 8 of the form as appropriate and sign Part 10 including your Medical Group # / Name and PCP # / Name. It is helpful to attach the doctor information from the BCBS website to your enrollment form.

(HMO) Finding a Primary Care Physician – You will need to choose a Primary Care Physician as part of the enrollment process (women may choose two – a general doctor and an OB/GYN). The best way to find a doctor is to look on the BlueCross BlueShield website at www.bcbsil.com, call them at (800) 892-2803, or ask your doctor if s/he is in the BlueCross HMO network. It is always best to double check with your doctor that s/he is still part of the network.

Additional Medical Insurance Information

Young Adult Enrollment Page

Forms

*Claim Form
*Student Certification Form

Drug Program

*Mail Order Prescription Program – Using the Mail Order Prescription Program, for certain maintenance type drugs you may receive a 90 day supply for the same co-pay you would pay when you receive a 30 day supply at the retail pharmacy.
*Prescription Drug Mail Order Form
*Prescription Drug Information
*Prescription Drug Formulary Update-2009
*Prescription Formulary List-2009
*Prescription Dispensing Limits-2009

Be a Better Healthcare Consumer

Medicare

*Medicare Secondary Payer Information
*Medicare Part D Creditable Coverage Disclosure Notice

Annual Notice

Women's Health

*Cancer Rights Act of 1998

Blue Access® Program - www.bcbsil.com/member

*Blue Care Connection Program Information
*New (1-10) Fitness Program - Making Fitness Easy, Fun and Affordable

HMO Specific Information

*HMO Transition of Care
*BC/BS HMO Infertility Network
*BC/BS HMO Infertility Policy

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