Medicare Supplement Application Forms

Who is this for?

If you want to apply for a Medicare supplement you can find the form here.

What you'll need to apply:

  • Your Medicare card
  • Your banking information and a voided check if you want to sign up for automatic payment withdrawal
  • Your Social Security number
2023 forms

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 without a guaranteed issue right, you’ll need to answer some health questions on your enrollment form.
  • Medicare supplement plans that cover the Part B deductible (Plans C, F, and high‑deductible F) will no longer be available for individuals who turned 65 or become eligible for Medicare on or after January 1, 2020. For those looking for an alternative to Plan C, F, or High-Deductible F, Blue Cross now offers Plan G.

Important information about your plan

The Medicare deductibles, coinsurance and copays listed are based on the 2023 numbers approved by the Centers for Medicare and Medicaid Services. You can go to any hospital, doctor or other health care provider in the U.S. or its territories that accepts medicare. You don't have to use our network. Blue Cross Blue Shield of Michigan administers Blue Cross medicare Supplement plans. Where you live, your age, gender and whether you use nicotine products (including e-cigarettes, vaping, and nicotine patches or gum) may affect what you pay for your plan. Your health status may also affect what you pay. This is a solicitation of insurance. We may contact you about buying insurance. Blue Cross Medicare Supplement plans aren't connected with or endorsed by the U.S. government or the federal Medicare program. 

If you're currently enrolled in Plan A or Plan C, you can stay with your plan as long as you pay your premium. You may enroll in Plan C if you've lost coverage under a group policy after becoming eligible for Medicare. You're also eligible if you had Plan C, then enrolled in a Medicare Advantage plan, and now would like to return to Plan C. You can do this as long as it's within the first 12 months of your Medicare Advantage plan. You're automatically eligible for Plan A if you're 65 or older. If you're under age 65, you are eligible for Plan A if you've lost coverage under a group policy after becoming eligible for Medicare. You can also enroll if you had Plan A, then enrolled in a Medicare Advantage plan, and now would like to return to Plan A. You can do this as long as it's within the first 12 months of your Medicare Advantage plan. You'll need to meet these requirements to apply for these plans.