• Blue Cross® Premier (Catastrophic, Bronze, Silver or Gold, Platinum)
  • Blue Cross® Silver, a Multi-State Plan or Blue Cross® Gold, a Multi-State Plan
  • Blue Cross® Metro Detroit EPO

Use this form: Automatic Payment Plan Enrollment Form (PDF)

Mail the form to:

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Blue Cross Blue Shield of Michigan
P.O. Box 2467
Detroit, MI 48231-2467