We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application.
Enrollment Forms:
Medical (Non-Medicare) and Dental Benefits Enrollment *
Medicare Advantage Plan and Dental Benefits Enrollment Form *
Health Benefit Dependent Change Form *
Continuation of Coverage Form *
Small Employer Exemption (SEE) Form
Non-Medicare Medical Claim Form:
To obtain a member-submitted claim form or international claim form, please visit the Highmark website at www.highmarkbcbs.com or contact customer service at 866.763.9471 for assistance.
Pharmacy Claim Form:
To obtain a pharmacy reimbursement form, please login to your account at www.express-scripts.com or contact customer service at 800.939.3781 for assistance.
Other Health Plan Related Forms:
Domestic Partnership Statement of Financial Interdependence Form *