Producer Forms

• Application for the addition of family members to an individual/family or group conversion plan
• Tobacco certification form
• Non-smoker certification form
• Underwriting plan change matrix
• Claim form
• Producer of record change form

Proposals

• Request for rates
• Census template

Pre-Renewal

Group size certification

Group Enrollment and Renewals

By the 1st of each month:

Completed enrollment/renewal materials for new/renewing groups must be received at Premera by the first of each month for groups requesting personal funding account setup to ensure eligibility by the start date.

By the 20th of each month for enrolling, (or 15th for renewing):

Completed enrollment/renewal materials must be received at Premera for all other products for new/renewing groups with effective dates of the 1st of the following month to ensure eligibility by the start date.

Follow these steps to complete your enrollment:

1. Complete the following necessary enrollment forms:
   For 2022 plans
   
   • 2022 group master application
   • 2022 group master application benefit selections
   
   For 2021 plans
   
   • 2021 group master application
   • 2021 group master application benefit selections
   
   Or circle, sign and date the rate exhibit to acknowledge your plan choice(s)
   • Enrollment spreadsheet (for groups with 10 or more enrolled employees)
   • Member enrollment and change application (for groups with under 10 enrolled employees)
   • Other coverage questionnaire
   • Waiver of coverage
2. Send completed enrollment materials to AKPBCSmallGrpSS@PREMERA.com.

Proposals

• Request for rates form (51-99)
• Census template (51-99)

Groups with 100 or more employees enrolled, please contact your Premera sales representative.

Pre-renewal

Group size certification

Group enrollments

Completed implementation 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 groups start date.

Follow these steps to complete your enrollment:

1. Required documents:

   Fully insured group master application
   Self-funded group master application

   Circle, sign and date the Rate Exhibit to acknowledge your plan choice(s)

   • Enrollment spreadsheet (membership adds/drops or plan changes)
   • Other coverage questionnaire
2. Return completed enrollment materials to Strategic Account Executive Bradley.Olson@premera.com and Implementation Account Specialist Kent.Doepel@premera.com.
   
   Completed enrollment materials must be received at Premera well in advance of the 1st of the month for new groups beginning coverage on the 1st of the following month to ensure eligibility and receipt of ID cards by the start date.

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.

Group renewals

Completed renewal documents must be received at Premera well in advance of the first of the month for renewing groups beginning coverage on the first of the following month to ensure eligibility and receipt of ID cards, by the groups start date.

Follow these steps to complete your renewal:

Circle, sign and date the Rate Exhibit to acknowledge your plan choice(s)

Required documents:

1. Group verification report (provided by Premera)
2. Enrollment spreadsheet (membership adds/drops or plan changes)
3. Other coverage questionnaire
4. Return your completed enrollment documents to your designated Account Manager and Implementation Account Specialist.

Note: Forms and documentation will be provided for any groups requesting self-funded or defined funded options.

Claim form

HSA, FSA, and HRA forms for new/renewing groups

• Personal funding account enrollment & change application
• 2021 Personal funding account setup form - for small groups
• 2022 Personal funding account setup form - for small groups up to 50 
• 2021 Personal funding account setup form - for large groups
• 2022 Personal funding account setup form - for large groups
• Funding Account ACH Authorization
• HSA Account Closure form
• HSA Designation of Beneficiary form
• HSA Trustee to Trustee Transfer form
• HSA Manual Claim form

• Express Scripts home delivery mail-order form - Order prescription drugs through the mail from Express Scripts. On behalf of Premera, Express Scripts is an independent company providing pharmacy benefits services.
• 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.

• Authorization Form Self-Funded Alaska
• Authorization Form Fully Insured Alaska
• Authorization for release of psychotherapy notes
• Disclosure accounting request
• Information Release Form - Give someone permission to obtain and discuss your personal and health information, including sensitive information such as substance abuse, reproductive health, and mental health. You can also authorize members on your plan to see your sensitive information on Premera.com or ConnectYourCare (medical funding account).
• Non-disclosure request
• Request for amendment of record
• Request for inspection of records

• Affidavit of domestic partnership
• Individual domestic partner eligibility requirements
• AFT Authorization form for individual major medical
• Producer of record change form
• Preventive screening services (non-grandfathered plans)
• Student status verification
• Waiver of coverage
• Request for certification of disabled dependent
• Deductible credit form
• Waiver of coverage
• Deductible credit form