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.
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