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MyBlueSM Medigap Application Form

Who is this for?

Medicare Help Center | Forms | Enrollment Forms

If you want to apply for a MyBlue Medigap plan, you can find the form here.

What you'll need:

  • Your Medicare card
  • Your banking information and a voided check if you want to sign up for automatic payment withdrawal
  • Your Social Security number
  • Your Michigan driver's license or state ID

Download the form below:

Mail to:

Mail Code H300
Blue Care Network of Michigan
P.O. Box 5043
Southfield, MI 48086-5043

 

Things to remember:

  • If you're enrolled in a Medicare Advantage plan, make sure you disenroll from that plan before you enroll in Medigap. You can find out how to disenroll from Medicare Advantage in our help center.
  • If you have any other health insurance coverage, don't cancel your plan until you get your Medigap ID card and welcome packet.
  • If you're enrolling outside a special enrollment period, you'll need to list your recent medical history and the prescription drugs you're taking on your enrollment form.