Medicare Supplement Application Forms

Who is this for?

If you want to apply for a Medicare Supplement or 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 for the plan you want to enroll in:

Mail to:

Blue Cross Blue Shield of Michigan
P.O. Box 44407
Detroit, MI 48244-0407
Fax: 1-866-392-7528

 

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 a Medicare supplement plan. 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 new 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.