- Out-of-Network Claim Form
- Seasonal Influenza Reimbursement Form
- Fitness Reimbursement Form
- Continuation of Care Form
- Coordination of Benefits Form
- Comcast Travel Reimbursement Form
- Application to Continue Coverage for a Disabled Dependent Child
Disabled dependents may be eligible to continue on the policy if proof of eligibility is met. To apply for disabled dependent coverage, complete and return the form above to:
Independence Blue Cross
c/o Enrollment Services
1901 Market Street
Philadelphia, PA 19103
Eligible full-time student dependents may be eligible for coverage until they reach age 26. Contact your Benefits Representative for information on how to enroll your student dependent.