| |
| |
Re-Enrollment Form
Not sure if you’re currently enrolled in Plan A or Plan B?
Just check your Medavie Blue Cross identification card. If you have Plan A, your card will show the code MA listed under Benefits List by your Drug Benefits. If you have Plan B, you’ll see CM listed there.
For information to assist you in your decision, please click here
Please check the appropriate box:
I am currently enrolled in Plan A and would like to switch to Plan B on April 1, 2010.
I am currently enrolled in Plan B and would like to switch to Plan A on April 1, 2010.
I understand my plan choice cannot be changed from April 1, 2010 to April 1, 2012 unless I experience a ‘life event’ such as marriage, divorce or the addition of a new dependent.
If we do not hear from you by March 15, 2010, we will assume you want to keep your current plan.
Employee Information
(all fields are mandatory)
Date:
Name:
Facility:
Identification Number from your Medavie Blue Cross ID Card:
| |
|