For your convenience, we've categorized our most frequently used forms.
If you can't find the form you need or require further assistance, please contact us.
Request for Rates
Group Size Attestation
By the 1st of each month:
By the 20th (for new groups) or the 15th (for renewing groups) of each month:
Follow these steps to complete your enrollment:
Complete the following necessary enrollment forms:
For 2016 plans
2016 Group Master Application
2016 Group Master Application Benefit Selections
or circle, sign and date the Rate Exhibit to acknowledge your plan choice(s)
2017 Member Enrollment and Change Application (for groups with under 10 enrolled employees)
Instructions for Auto Enrollment Spreadsheet
Auto Enrollment Spreadsheet (for groups with 10 or more enrolled employees)
Other Coverage Questionnaire
Waiver of Coverage
Return completed enrollment materials to AlaskaRFPs@premera.com.
By the 20th of each month:
Group Master Application 51 - 99
Circle, sign and date the Rate Exhibit to acknowledge your plan choice(s)
Member Enrollment and Change Application (for groups with under 10 enrolled employees)
Note: Forms and documents will be provided for any groups requesting self-funded or defined funded options. Binder check will be required for Stop Loss.
Completed implementation materials must be received at Premera well in advance of the first of the month for new groups beginning coverage on the first of the following month to ensure eligibility, plus receipt of ID cards, by the start date.
Follow these steps to complete your implementation:
REQUIRED documents for implementation:
Group Master Application
For the best member experience, please submit the following by the 15th of the month prior to start date:
Enrollment spreadsheet will be required. Please contact your Premera sales professional to obtain this document.
This section provides forms for Express Scripts Home Delivery, Pre-approve, Prescription Drug Reimbursement, and other pharmacy-related forms.
Health, Allergy and Medication Questionnaire
Pharmacy Mail-Order Form
Prescription Drug Reimbursement
Prescription Drug Reimbursement Form (for Alyeska Medical Retirees)
Secondary Insurance Drug Claim
Medicare Secondary Payer - Form used for employer groups to report group size and Medicare beneficiary changes to Premera
MSP Change Form
Medicare Prescription Drug Program Forms
Medicare Prescription Drug Program Creditable Coverage Notice
Medicare Prescription Drug Program Non-Creditable Coverage Notice
Use these forms to enroll or renew your group onto a personal funding account, such as an FSA, HRA, or HSA.
Personal Funding Account Enrollment and Change Application
Personal Funding Account Setup Form - For Metallic Groups up to 50
This section includes Release of Information forms.
Authorization for Release of Healthcare Information and Records
Authorization for Release of Psychotherapy Notes
Disclosure Accounting Request
Request for Amendment of Records
Request for Inspection of Records
Check this section for other frequently used forms including Affidavits of Domestic Partnership and more.
Electronic Funding Authorization
Affidavit of Domestic Partnership
Group Eligibility Adjustment Form
Preventive Screening Services (non-grandfathered plans)
Request for Certification of Disabled Dependent
Self-Funded Health Plan Authorized Representative Disclosure Form
Student Status Verification
Essential Preventive Health Services for Adults (non-grandfathered plans)
Essential Preventive Health Services for Adults (grandfathered plans)
Deductible Credit Form
Manage all member information in one convenient place.