Optional Supplemental Dental, Vision and Hearing Plan Selection Form Date: ____________________________________ Member name: ________________________________Enrollee number: _________________________ I’d like to add the optional supplemental dental, vision and hearing plan to my base BCN Advantage plan.   Renewing BCN Advantage individual members can enroll in this plan from Oct. 15 through Dec. 31. New BCN Advantage individual members can enroll in this plan at the time of initial enrollment or during Medicare’s annual election period, Oct. 15 through Dec. 7. Check the box below to add extra dental, vision and hearing coverage to your BCN Advantage plan: □ BCN Advantage Optional Supplemental Dental, Vision and Hearing Plan Available to all BCN Advantage individual members for an additional $19.90 monthly premium  Dental fluoride treatments and brush biopsies  Help with the cost of fillings, root canals, simple extractions, crowns and crown repairs  Reduced cost for contact lenses, or a combination of eyeglasses, lenses or frames  Reduced cost for hearing aids, annual hearing aid exam, and hearing aid fitting and evaluation Paying your plan premium You can pay your monthly plan premium and the premium for the optional supplemental plan, including any late enrollment penalty you have or may owe, by mail, phone, online or electronic funds transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board check each month. Please note, if you already have your premium automatically deducted, you may have to request the deduction again to include the additional premium. If you don’t select a new payment option, your current method of payment will remain in effect. Please select a premium payment option: 1. Electronic funds transfer (EFT) allows your payment to be automatically withdrawn from your bank account every month. Please enclose a VOIDED check or provide the following: Account holder name: ____________________________________________________ Bank routing number: ____________________________________________________ (First set of numbers on left side of check) Bank account number: ____________________________________________________ (Second set of numbers located in the center of check) Account type: Checking Savings 2. Receive a monthly bill. You may choose from the following payment methods: Pay online: To learn how to pay your premium online, go to www.bcbsm.com/ebilling. Pay by phone: You can call 1-855-321-5346, 24 hours a day, seven days a week, or call BCN Advantage Customer Service at 1-800-450-3680, 8 a.m. to 8 p.m., Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users should call 711. Pay by mail: Mail your check, cashier’s check or money order made payable to Blue Care Network directly to Blue Care Network, P.O. Box 33608, Detroit, MI 48232-5608. BCN Advantage is an HMO-POS and HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. DF 14021 SEP14 H5883_F_OptSuppShortFrm2015 CMS Approved 09252014 3. Automatic deduction from your monthly Social Security or RRB benefit check. (The Social Security or RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.) Conditions of enrollment By completing this application form, I agree to adding the optional supplemental dental, vision and hearing plan for $19.90 per month, which is in addition to my monthly base BCN Advantage plan premium. I understand that the additional dental, vision and hearing coverage is subject to the terms and conditions stated in my BCN Advantage Evidence of Coverage. I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State of Michigan) on this application means that I have read and understand the contents of this application. If signed by an authorized individual, this signature certifies that this person is authorized under state law to complete this enrollment, and documentation of this authority is available upon request by BCN Advantage or Medicare. Signature: Today’s date: If you are the member’s authorized representative, you must sign above and provide the following information: Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ Phone number: (_____________) _____________- __________________________________________ Relationship to enrollee: _______________________________________________________________ If you have any questions, please call BCN Advantage Customer Service at 1-800-450-3680. TTY users should call 711. We are open 8 a.m. to 8 p.m., Monday through Friday, with weekend hours Oct. 1 through Feb. 14. Please mail this completed form to: BCN Advantage — Mail Code H300 20500 Civic Center Drive Southfield, MI 48076 You may also enroll in the optional supplemental dental, vision and hearing vision plan online. Go to www.bcbsm.com/bcna and click on the For Members. Select the Medicare Advantage Extras and click on Optional Supplemental Dental, Vision and Hearing Plan. The benefit information provided is a brief summary, not a complete description of benefits. Limitations, copayments and restrictions may apply. Benefits, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. For more information, contact the plan. You must use our contracted providers for your care. You must continue to pay your Medicare Part B premium.