Check It Out

Pay premiums automatically from your bank account.

Required fields are noted with an asterisk *.

Subscriber Information
Address Information
Financial Institution Information
The ABA/transit routing number is the first 9 numbers on the bottom left corner of your check. The account number is the 10 numbers on the bottom right corner of your check.

By completing this form, I/we authorize Capital BlueCross and its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company®, Keystone Health Plan Central®, and the financial institution named above, to deduct the amount of the premium for health care coverage from my/our account on the designated day and transfer such amount directly to Capital BlueCross.

If the designated day is a holiday, the premium payment will be deducted on the next business day.

I/we agree to maintain sufficient funds in the account to permit these deductions. If the account does not have sufficient funds at the time of transfer, I/we understand that my/our Capital BlueCross health care coverage may be canceled.

By typing my full name below and submitting this form, I understand that I am creating an "Electronic Signature" that carries the same legal obligations of a written signature name.

(acts as electronic signature)

Clicking 'submit' certifies the information provided is true and correct.

Updated October 1, 2018