medicare.highmarkhealthplan.com Open in urlscan Pro
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1 forms found in the DOM

POST /call/CodeGate

<form class="welcomeBox" action="/call/CodeGate" method="post" novalidate="novalidate">
  <h1>Welcome</h1>
  <p>If you have a Priority Code, enter it here and we'll populate this information for you.</p>
  <h2>Priority Code (Optional)</h2>
  <input class="" data-val="true"
    data-val-length="The Priority Code you entered is incorrect or has already been used. Please re-enter your code in case there was an error. Your Priority Code is six characters (XXX - XXX) and is located in the letter or email we sent you."
    data-val-length-max="7"
    data-val-regex="The Priority Code you entered is incorrect or has already been used. Please re-enter your code in case there was an error. Your Priority Code is six characters (XXX - XXX) and is located in the letter or email we sent you."
    data-val-regex-pattern="([\da-zA-Z]{3})-([\da-zA-Z]{3})" id="PriorityCode" name="PriorityCode" placeholder="" type="text" value="">
  <span id="pcalert"><span class="field-validation-valid error" data-valmsg-for="PriorityCode" data-valmsg-replace="true"></span></span>
  <div class="welcomeBoxDivider">
    <hr class="hr">
    <h3>OR</h3>
    <hr class="hr">
  </div>
  <p>Don't have a Priority Code? Enter your ZIP Code to get started.</p>
  <div id="left" class="left welcomeBoxColumn">
    <h2>ZIP Code</h2>
    <input class="" id="ZipCode" maxlength="5" name="ZipCode" placeholder="(e.g., 15211)" type="text" value="">
    <span class="field-validation-valid error" data-valmsg-for="ZipCode" data-valmsg-replace="true"></span>
  </div>
  <div id="right" class="right welcomeBoxColumn">
    <h2>How did you hear about this website?</h2>
    <select id="habt" name="habt">
      <option value="">How did you hear about this website?</option>
      <option value="Mail">Mail</option>
      <option value="Email">Email</option>
      <option value="Searched_online">Searched online</option>
      <option value="TV">TV</option>
      <option value="Facebook">Facebook</option>
      <option value="Twitter">Twitter</option>
      <option value="Brochure">Brochure</option>
      <option value="Friends_And_Family">Friends &amp; Family</option>
      <option value="Other">Other</option>
    </select>
    <span class="field-validation-valid error" data-valmsg-for="habt" data-valmsg-replace="true"></span>
  </div>
  <button type="submit" class="orangeButton" id="submit-btn">
    <span>Continue <i class="fa fa-caret-right"></i></span>
  </button>
</form>

Text Content

WELCOME

If you have a Priority Code, enter it here and we'll populate this information
for you.


PRIORITY CODE (OPTIONAL)

--------------------------------------------------------------------------------


OR

--------------------------------------------------------------------------------

Don't have a Priority Code? Enter your ZIP Code to get started.


ZIP CODE


HOW DID YOU HEAR ABOUT THIS WEBSITE?

How did you hear about this website? Mail Email Searched online TV Facebook
Twitter Brochure Friends & Family Other
Continue


HAVE MEDICARE QUESTIONS? CALL 1-866-764-0519 FOR HELP WITH MEDICARE PLANS OR
ENROLLMENT.
(TTY USERS CALL 711) 8 A.M.-8 P.M., SEVEN DAYS A WEEK

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*There is no obligation to enroll.

Highmark Choice Company and Highmark Senior Health Company are Medicare
Advantage plans with a Medicare contract. HM Health Insurance Company is a PDP
plan with a Medicare contract.Enrollment in Highmark Choice Company, Highmark
Senior Health Company, and HM Health Insurance Company depends on contract
renewal. Highmark Blue Shield, Highmark Choice Company, Highmark Senior Health
Company, and HM Health Insurance Company are independent licensees of the Blue
Cross and Blue Shield Association.

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