Demographic Form

---

Plan Selection

There are no plans for the current zipcode.

Please provide demographic information and plan selection will be available.

District of Columbia: CareFirst BlueCross Blue Shield Advantage Complete (PPO) Premium: $42 per month District of Columbia: CareFirst BlueCross BlueShield Advantage Salute (PPO) Premium: $0 per month MARYLAND: Not available in Baltimore City and Baltimore County - CareFirst BlueCross BlueShield Advantage Essential (PPO) Premium: $0 per month MARYLAND: Available in all counties - CareFirst BlueCross Blue Shield Advantage Complete (PPO) Premium: $42 per month MARYLAND: Available in all counties - CareFirst BlueCross BlueShield Advantage Salute (PPO) Premium: $0 per month CareFirst BlueCross BlueShield Advantage DualPrime (HMO-SNP) $0–$40.30 per month (Based on your level of “Extra Help”)

Demographics

• Last Name (As On Medicare Card)
• First Name (As On Medicare Card)
• M.I.
• Prefix Dr.MissMr.Mrs.Ms.
• Birth Date
• Sex

  Male Female

• Phone Number
• Alternative Phone Number
• Email

Permanent Residence Address

• Permanent Residence Street Address
  (Don’t enter a PO Box Note: For individuals 
  experiencing homelessness, a PO Box may be 
  considered your permanent residence address.)

• Street Address Line 2

• Zipcode

• City
• County
• State Choose a stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoVirgin Islands

Mailing Address

Same As Permanent Address

• Mailing Address, if different from your Permanent Address (PO Box allowed)

• Street Address Line 2

• Zipcode

• City
• County
• State Choose a stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoVirgin Islands

Next