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
Blue Care Network HMO > Enroll
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
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