Form 1095-B Request

Please enter the information below to request a Form 1095-B in the mail. Only the primary Subscriber (i.e., not a Dependent) on the policy/plan may request and receive a Form 1095-B.

If you have coverage through a self-insured employer plan, the Federal Employee Program, as an active employee through the Mississippi State and School Employees’ Health Insurance Plan or have a Medicare Supplement policy, Blue Cross & Blue Shield of Mississippi does not issue your Form 1095-B and you should not submit the request below.

If you have COBRA or Retiree coverage through the Mississippi State and School Employees' Health Plan, please use the State and School Employees’ Health Insurance Plan COBRA/Retiree Form 1095-B Request.

BCBSMS Subscriber ID - Do not include the prefix. View Example

Subscriber's Last Name

Subscriber's Date of Birth - Format: MM/DD/YYYY

Subscriber's Zip Code

Request Form 1095-B