This application may be used for 2022 individual and family coverage through either Blue Cross Blue Shield of Michigan (BCBSM) or Blue Care Network of Michigan (BCN), depending on which medical plan you choose. Dental plans, dental with vision, and adult vision plans are only offered through BCBSM, but can be paired with BCBSM or BCN medical plans.
Complete all fields unless otherwise noted. Review your application for accuracy, then sign and date. Your information will be used and disclosed only as permitted by our Notice of Privacy Practices.
If you’d like to apply for a subsidy or tax credit, are age 30 or older and would like to check your eligibility for a hardship exemption to enroll in a Value Plan or are Native American and eligible for additional cost-sharing benefits, contact a health plan advisor at 1-888-899-3012 or your Blue Cross or BCN Agent.
To get individual medical, dental, dental with vision, or adult vision coverage, you must be a Michigan resident when your coverage starts and intend to reside in Michigan. If you're eligible for Medicare, you’re not eligible for individual medical coverage.