Forms and Brochures

The following forms and brochures are available to help group administrators better manage the administration of their organization’s benefits program.

Application Forms

Ready to join one of our plans?

Keystone 65 HMO

Personal Choice 65 PPO

Security 65 (Medigap)

Select Option (PDP)

Evidence of Coverage (EOC)

The Evidence of Coverage is a resource guide to your health care coverage. It explains conditions and limitations of coverage and plan rules.

Keystone 65 HMO

Personal Choice 65 PPO

Select Option

Benefits administrator guide (coming soon)

The benefits administrator guide describes Independence Blue Cross processes and procedures, such as eligibility policy, enrollment procedures, premium invoicing, and coordination with Medicare.

Disenrollment Forms

Keystone 65 HMO

Personal Choice 65 PPO

Select Option