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Carrier Agreements

For on-exchange policies, please visit your carrier's website:

Blue Cross Blue Shield of Oklahoma

For off-exchange policies, please view your carrier's application agreement below:

Blue Cross Blue Shield of Oklahoma Application Agreement

BY COMPLETING AND SIGNING THIS FORM, I UNDERSTAND AND AGREE TO THE FOLLOWING:

  • This Application is not coverage. Coverage will not begin until (1) the effective date of the policy and (2) the first month’s payment is made.

  • If I use an agent or broker, they cannot accept risks or change BCBSOK policies or rules.

  • If an agent, producer or broker was helping me to purchase an individual or family health or dental plan, BCBSOK may pay the broker a commission and/or other payment. If I want more detail about any payment to the agent or broker, I should ask the agent or broker.

  • If any person knowingly submits a false claim for payment of a loss or benefit or falsely misstates an important fact on this Application, coverage may be rescinded. This includes false claims or facts about me or any of my dependents. Rescission cancels the coverage back to the first day it became effective. I will be given at least 30 days’ written notice before my coverage or that of my dependents is rescinded.

  • My monthly premium will be calculated using factors approved by the State’s Department of Insurance and other applicable State and Federal laws and regulations. Rates are calculated based on age, tobacco use and geographic rating factors. These factors are also used to calculate premiums for any dependents covered on my policy.

  • Coverage will start on the plan effective date only if the first monthly payment is received in full before that date.

  • I allow any of the following people or organizations to share my health information with BCBSOK or their authorized representative:

-Health professionals, hospitals, or clinics

-Other health or health-related facilities

-Government agencies

-Pharmacy benefit managers, clearinghouses, or retail stores

-Any other persons or firms required by law

-This information may include:

-Copies of records about advice, care or treatment that were given to me and/or my dependents -Information about the prescription and use of drugs or alcohol (without limitation) -Information about mental illness

  • BCBSOK may review and research its own records for information.

  • BCBSOK will share collected information only as needed with medical entities to help manage my care.

  • Information shared with my authorization may be re-shared by BCBSOK as allowed or required by law. If such sharing is required, the person or agency getting the information will be responsible for protecting it.

  • This authorization is valid for two years from today, or until I cancel coverage.

– I have the right to cancel the authorization at any time, in writing, by contacting BCBSOK. – I or anyone I authorize to represent me will receive a copy of this authorization upon request. – Any cancellation will not affect the activities of BCBSOK before the date such cancellation is received by BCBSOK.

  • I present any statements and answers on this Application as FACTS. To the best of my knowledge and belief, they are true and complete. These facts are the basis of my Application.

  • The Application will become a part of the contract between BCBSOK and me.

  • My agent (if I have one) and I confirm that I have read and understood the Application.

  • I have reviewed the details of the plan I chose.

  • This individual or family plan is meant to be paid as my personal expense.

  • Only I or a family member, or an allowed third party as outlined in the Application will pay BCBSOK directly.

  • BCBSOK does not accept payments directly from third parties except from those listed on page 8 (family members, Required Entities, certain private nonprofit foundations).

  • If these rules are broken, any payments made by a third party will not be credited to my account or coverage. These payments may not be refunded to me. This may result in the cancellation of my coverage for nonpayment.

WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE FOUND GUILTY OF A FELONY IN A COURT OF LAW.