How to Enroll

Enroll by Mail

Keystone 65 HMO enrollment application

Personal Choice 65 PPO enrollment application

Select Option PDP enrollment application

MedigapSecurity enrollment application

Request a full enrollment kit

Completing your enrollment application

Each enrollee will need to complete an application.

Indicate the group number of the desired product on the completed enrollment application from the chart below:

• Indicate the desired effective date on the completed application. This will always be the first of a month.
• Send completed applications within a full month of the desired effective date.

Send your completed enrollment applications to:
Independence Blue Cross
1901 Market Street
Government Programs – 28th floor
Attn: Kathy Burton
Philadelphia, PA 19103

How to pay your monthly premium

No premium payment is required at the time you apply. A monthly premium invoice will be sent to you. You have three options for remitting payment:

1. Pay by mail.
2. Use ZipCheck. This is an Electronic debit from your checking or savings account (not available with MedigapSecurity or Select Option PDP).
   
   
   • Keystone 65 HMO ZipCheck authorization form
   • Personal Choice 65 PPO ZipCheck authorization form
3. Use eBilling. Visit ibxpress.com to set up online premium payment.