We're here to help! If you have any questions or need help completing this form, contact a BCBSVT exchange specialist at (800) 255-4550, Monday - Friday, 8:00 a.m. to 4:30 p.m.
*Indicates a required field.
*Contact Name/Benefit Manager
You may select one benefit plan.
You may select up to nine benefit plans.
Click on any benefit plan below to view the Summary of Benefits and Coverage (SBC) or click here to compare all our qualified health plan offerings.
Please list all currently covered employees and their plan selection.
Note: Employees will transfer to their current plan type (i.e. single or family).
You will need to complete and submit a Small Group Change Form for any of the changes listed below.
Follow the instructions on the form to submit the completed form.
By typing my name in the "Authorized by" field below, I confirm the following: