2022 BCBS BlueCare Plus Order Form

1 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.

2 1 $ . $ . 2 $ . $ . 3 $ . $ . Subtotal from Other Side $ . Sales Tax $ . Total Order $ . Ordering more than three items? 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 . H3259_22 OTCOF_C (11/21). STEP 2 - PRODUCT SELECTION (Continued). Item # Product Quantity Unit Price TOTAL. 4 $ . $ . 5 $ $.. 6 $ $.. 7 $ $.. 8 $ $.

3 9 $ . $ . 10 $ . $ . 11 $ . $ . 12 $ . $ . 13 $ . $ . 14 $ . $ . 15 $ . $ . 16 $ . $ . 17 $ . $ . 18 $ . $ . Subtotal $ . Please note: We can't accept cash, checks, credit cards or money orders. Items ordered as part of this benefit may be subject to sales tax. If applicable, sales tax will be applied and paid for from your OTC. allowance. A representative may contact you if we have questions about this form . We'll send you a new Order form with your items. But you can also download one at: STATE TAX RATES. The state tax rates listed below include the local and municipal tax rates, if applicable. These rates are provided as a guide to help you place your OTC Order using this Order form .

4 Tax rates may vary, and we may need to contact you directly if there is any question related to this Order form . The final Order total, including applicable sales tax, will be included in your Order packing slip. State Combined Rate State Combined Rate Alaska Montana Alabama North Carolina Arkansas North Dakota Arizona Nebraska California New Hampshire Colorado New Jersey Connecticut New Mexico Nevada Delaware New York Florida Ohio Georgia Oklahoma Hawaii Oregon Iowa Pennsylvania Idaho Rhode Island Illinois South Carolina Indiana South Dakota Kansas Tennessee Kentucky Texas Louisiana Utah Massachusetts Virginia Maryland Vermont Maine Washington Michigan Wisconsin Minnesota West Virginia Missouri Wyoming Mississippi