Religious Accommodation Limited Choice Enrollment Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're a Blue Cross Blue Shield of Michigan or Blue Care Network member and your employer doesn't cover contraceptives or contraceptive services because they have a religious accommodation, you can use this form to get no-cost contraceptive coverage.

What is a religious accommodation?

Some nonprofit religious organizations can object to contraceptive coverage on religious grounds. Some of these groups choose to get a religious accommodation from the Affordable Care Act's requirement to provide contraceptive coverage for their employees.

If you work for an employer with a religious accommodation, you'll have access to contraceptive coverage through your Blues plan. We cover sterilization and uterine devices, as well as approved generic contraceptive drugs. Some name brand drugs or some over the counter drugs may be covered, but check your plan information to be sure.

If you visit a participating Blues provider, we'll cover 100 percent of your contraceptive services. We'll send you a letter with more information about the coverage you can choose.

To get started, fill out the Religious Accommodation Limited Choice Enrollment form (PDF). You may have received this in the mail as the RA Choice Enrollment form.

You'll need to know your:

  • Social Security number
  • Group number or Group ID number
  • Subgroup
  • Class ID

After you complete the form, mail or fax it to the address or number listed on the form, so we can get you enrolled.

Religious Accommodation Limited Choice ID card

After you're enrolled, we'll send you this ID card. When you go to the doctor for contraceptive services or fill a prescription that's covered under your plan, show this card and you won’t have to pay upfront for those services. The provider will send us the bill.

If you don’t show this ID card, we can't pay for your contraceptive services or prescriptions. If that happens, you'll need to contact your doctor or pharmacist to adjust your bill with the information from this card.

If you already paid for a contraceptive service or prescription before you got your card, you'll need to go through the appeals process for reimbursement.