Medical and Dental Claim Form - Submit a medical or dental claim when the health care provider is not submitting it on your behalf.
Other Coverage Questionnaire - You may be asked to complete this form to provide information about other coverage you may have.
Incident Questionnaire - You may be asked to complete this form after sustaining an injury or being involved in an accident.
International Claim Form - Use this form when you need to submit a claim for services you incurred outside the United States
Massage Therapy Prescription Submission Form - Submit this form for coverage of massage therapy services.
Transition of Care Flyer - New to Premera? Use this form to understand how to transition your care from your previous carrier.
Express Scripts Home Delivery Order Form - Complete this form to have Express Scripts fill your prescriptions by mail.
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 - Submit this form to have Premera pay you back for your prescription costs.
Health Savings Account Manual Claim Form - Use this form to submit a manual claim for reimbursement from your Health Savings Account associated with your Health Savings Plan (HSP).
Reimbursement Account Manual Claim Form (HCRA/HRA) - Use this form to submit a manual claim for reimbursement from your Health Care Reimbursement Account.
Dependent Care Reimbursement Account Claim Form - Use this form to submit a manual claim for reimbursement from your Dependent Care Reimbursement Account.
Reimbursement Account Refund Form - Use this form to refund your Reimbursement account for amounts used for ineligible items, or for claims that you also received reimbursement from another source.
HSA Transfer to UMB from Other Trustee Form - Use this form to transfer funds into your Health Savings Account with UMB.
Health Care Information Non-Disclosure Request (NDR) Form - Use this form to deny release of your health information to a specific person(s).
Starbucks Appeals Process - Learn more about Premera’s appeal process and what to do if you disagree with how a claim was paid.
Authorization for Appeals - Use this form to provide your approval for another party to submit an appeal on your behalf.
Flight Assist Reimbursement Guidelines & Form - Hawaii Partners Only: Use this form to request reimbursement after you have completed your interisland travel to see a medical specialty provider.
Call us at 877-728-9020