This form must be received by SSC Benefits Transactions within 14 days of the date you receive an email with the subject line, "Living Outside the Premier Care Service Area." Coverage for you and your dependent(s), if any, has been defaulted into the Comprehensive Major Medical health plan. Complete and return this form to select a different plan. Your coverage will be effective the date you are newly eligible to enroll in a University of Michigan health plan.
If you move and you need to change your coverage, complete this form within 30 days of your move. Your new coverage will become effective the first day of the month after your move. Your next opportunity to make a change will be the next Open Enrollment period, with the change effective January 1.