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 *

Statement of Health 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 *

Health Benefits Automatic Credit Reduction Form

Protected Health Information Release Form