Use the categories below for quick access to the forms you need. If you require further assistance, please contact us.
Please choose your group size to access enrollment materials appropriate for your group.
Request for Rates
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
This section provides forms for individual and family plans
Enrollment Application - Premera will begin processing applications when open enrollment starts November 15.
Individual and Family Enrollment Application - (For non-grandfathered plans with effective dates on or after May 1, 2012)
Application for the Addition of Family Members to an Individual/Family or Group Conversion Plan
Existing Member Dental Application
New Member Dental Application
Plan Change Form
AFT Authorization Form for Individual Major Medical
Tobacco Certification FormFor plans as of 1/1/14 enrollment dates
Non-Smoker Certification Form
For plans prior to 1/1/2014
Underwriting Plan Change Matrix - For plans with effective dates on or after May 1, 2012.
Please note: The following plans are available for purchase 10/1/2013 for an effective start date of 1/1/2014
Forms and supplies for requesting a proposal
Small Groups (2-199 employees)
Group Risk Profile for Community Rated Groups 2-99
Health Questionnaire 2-50
Health Questionnaire 51-99
View or print this form
This section provides Fax-back forms to submit a request for review and approval and forms related to Express Scripts Home Delivery or prescription drugs
Express Scripts Home Delivery Mail-Order Form - Order prescription drugs through the mail from Express Scripts.
Health, Allergy & Medication Questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Prescription Drug Reimbursement Form - Apply for reimbursement of your prescription costs.
This section provides 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 Record
Request for Inspection of Records
Affidavit of Domestic Partnership
Individual Domestic Partner Eligibility Requirements
HSA Authorization Form for UMB Bank
Producer of Record Change Form
Preventive Screening Services (non-grandfathered plans)
Student Status Verification
Information for plans closed to new membership as of May 1, 2009
2013 Grandfathered Plan Rate Sheet
2014 Grandfathered Plan Rate Sheet
Non-Grandfathered Plan Rate Sheet - (For closed plans with original effective dates from April 1, 2010 to April 15, 2010)
Non-Grandfathered Plan Rate Sheet - (For closed plans with original effective dates from May 1, 2010 until Dec. 15, 2010)
To order individual products and supplies:
Fill out the:
2015 Producer Supply Form
2014 Producer Supply Form
2014 Medicare Supplement Supply Order Form
Save a copy for your records.
Email it to Producer Supply. Or fax the completed form to 907-258-1619.