For your convenience, we’ve categorized our most frequently used forms below.
If you can’t find the form you need or require further assistance, please contact us.
Please choose your group size to access enrollment materials appropriate for your group.
By the 1st of each month:
By the 20th of each month:
Follow these steps to complete your enrollment:
Complete the following necessary enrollment forms:
2015 Group Master Application 1 - 50
2015 Group Master Application Benefit Selections 1 - 50
Member Enrollment and Change Application
Other Coverage Questionnaire
Waiver of Coverage
Deductible Credit Form
2015 Group Master Application 51 - 99
Circle. sign and date the Rate Exhibit to acknowledge your plan choice(s)
Enrollment spreadsheet will be required. Please contact your producer or Premera account manager to obtain this document.
Once group profile information has been received from the producer, the following items may be needed:
Group Master Application
Group Verification Report sent via EDGE
Deductible credit applications will be ordered based on timely communications with producers and Premera account managers.)
Note: Forms and documentation will be provided via the Premera account manager and account coordinator for any groups requesting self-funded or defined funded options.
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
Please choose your group size to access renewal materials appropriate for your group.
Follow these steps to complete your renewal:
Non-Grandfathered groups - complete the following forms:
2015 Group Master Application Benefit Selections
2014 Group Master Application Benefit Selections
Grandfathered groups - complete the following forms:
Return completed enrollment materials and payment to your Premera account manager at:
Premera Blue Cross Blue Shield of Alaska2550 Denali St #1404Anchorage, AK 99503
Non-Grandfathered groups - complete the following necessary renewal forms:
Deductible credit applications will be ordered based on timely communications with producers and Premera account managers.
Grandfathered groups - complete the following necessary renewal forms:
Group Verification Report sent via EDGE - Circle, sign, and date the Rate Exhibit to acknowledge your plan choice(s)
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 Creditable Coverage Notice – Employer Template
Medicare Prescription Drug Program Non-Creditable Coverage Notice
Medicare Prescription Drug Program Non-Creditable Coverage Notice – Employer Template
Group Risk Profile for Community Rated Groups 2-99
Request for Rates
View or print frequently used claim forms.
This section provides forms for Express Scripts Home Delivery, Prior Authorization, 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
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.
Affidavit of Domestic Partnership
Electronic Funding Authorization
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)
Manage all member information in one convenient place.