Enrollment Wizard: Medical Benefits: Enroll

Welcome, Tom A. Adams

Enrollment Summary

Steps
	1.	Instructions
	2.	Personal Information
	3.	Dependents
	4.	Confirm Information
	5.	Medical Benefits
	6.	Dental Benefits
	7.	Vision Benefits
	8.	Disability Benefits
	9.	Life & Accident Benefits
	10.	FSA Benefits
	11.	Other Benefits
	12.	Beneficiary Information
	13.	Confirm and Submit

VIEW CURRENT BENEFITS SUMMARY

Medical Benefits
Cigna Health Plan > Enroll

You are currently enrolled in the Blue Care Network HMO. By enrolling in the Cigna Health Plan, enrollment in the Blue Care Network HMO will be canceled.

Please select plan coverage and dependents (if applicable).

Enrollment Effective Date: 09/13/2001

Coverage:

	Employee Cost *	Company Cost *
Employee	$90.80	$40.33
Employee + Spouse	$142.92	$56.75
Employee + Child(ren)	$162.63	$91.23
Family	$384.36	$116.83

* Per pay period

Note: Place cost note here.

Employee PCP ID:

Current Patient:

Yes No

To obtain your PCP's ID, please visit your Provider Directory web site, by clicking on the link provided below.

Dependents to be covered:

		PCP ID	Current Patient
Jane C. Adams	(Spouse)		Yes No
Jill A. Adams	(Child)		Yes No
Ralph A. Adams	(Child)		Yes No
Penelope Adams	(Child)		Yes No

If a dependent is not listed under your list of dependents to be covered, click Add.

Provider Directory:
http://www.yahoo.com/

Enrollment Related Form(s):
- BCBSM Employee Enrollment

Required fields