2022 BCBS BlueCare Plus Order Form

2022 Over-the-Counter (OTC) Catalog Order form STEP 1 - COMPLETE YOUR INFORMATION BELOW. Member ID (found on plan member ID card) Date of Birth Card Number First Name Last Name and Suffix MI. Street Number Street Name Apt/Suite #. City State ZIP Code Please check box if this is a new address Email* (Optional) Daytime Phone Mobile Phone* (Optional). *By providing your email address/mobile phone number to us, you consent that we may send communication to you via email/text. Mobile service provider's message and data rates may apply. STEP 2 - PRODUCT SELECTION. Item # Product Quantity Unit Price TOTAL.

Turn to the back side of this form. Once your order is ready, you can mail the completed form to us using the postage-paid envelope we’ve provided. If you don’t have this envelope, you can mail it to OTC Service Center; PO Box 526266; Miami, FL 33152-9819. Your order total will be applied to your balance based on when we get your form.

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