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.
Completed enrollment materials must be received at Premera for new groups by the 20th of the month to ensure eligibility by the plan start date.
Send completed enrollment materials to AKPBCSmallGrpSS@PREMERA.com.
No action is necessary unless plan or group information changes are requested. Send change requests to AKPBCSmallGrpSS@premera.com and your designated account team no later than the 10th of the
month prior to the group’s renewal date by completing the group verification report and/or benefit selection worksheet.
Groups with 100 or more employees enrolled, please contact your Premera sales representative.
Completed enrollment materials must be received at Premera well in advance of the first of the month to ensure eligibility and receipt of ID cards by the plan start date.
Return completed enrollment materials to Senior Sales Manager Bradley.Olson@premera.com and Implementation Account Specialist Kayla.Koeckritz@premera.com.
Note: Additional forms will be provided for self-funded and Optiflex funding arrangements.
Completed renewal documents and written confirmation must be received at Premera well in advance of the first of the month to ensure eligibility and receipt of ID cards by the group's renewal date.
Return completed renewal documents to your designated Account Manager and Implementation Account Specialist.
Note: Additional forms will be provided for any groups moving to self-funded or Optiflex funding arrangements.
Medicare Secondary Payer (MSP) - this form is used for employer groups to report group size and Medicare beneficiary changes to Premera
MSP change form
Medicare prescription drug program formsMedicare prescription drug program creditable coverage noticeMedicare prescription drug program non-creditable coverage notice
This section provides forms for Express Scripts home delivery, prescription drug reimbursement, and other pharmacy-related forms.
Health, allergy, and medication questionnairePharmacy mail-order formPrescription drug reimbursementPrescription drug reimbursement Form (for Alyeska Medical Retirees)Secondary insurance drug claim
By the 1st of each month:
Completed enrollment/renewal materials for new/renewing groups must be received at Premera for HRA and HSA products for groups beginning/renewing coverage on the 1st of the following month to ensure eligibility is active on the start
Use these forms to enroll or renew your group into a personal funding account, such as an FSA, HRA, or HSA.
This section includes release of information forms.
Check this section for other frequently used forms.
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