Below you'll find a variety of our most frequently used employer forms. If you can't find the form you need or require further assistance, please contact us.
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Request for rates small groupCensus spreadsheet template
This section contains support materials including group renewal checklists and enrollment and change applications.
Transition of care formFunding Account ACH Authorization
Form used for employer groups and multiple employer groups to report group size and Medicare beneficiary changes to Premera that may impact Medicare secondary payer (MSP) rules.
MSP change form
Get forms for Express Scripts Home delivery, pre-approval and prescription drug reimbursement.
Mail-order form - Order prescription drugs through the mail from Express Scripts. Express Scripts Home Delivery is an independent company that provides mail-order pharmacy services on behalf of Premera Blue Cross.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.
Information release forms - 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 for personal funding accounts.Authorization for release of psychotherapy notesDisclosure accounting requestNon-disclosure requestRequest for amendment of recordsRequest for inspection of records
Affidavit of domestic partnership group plansGroup eligibility adjustment formMedicare prescription drug program non-creditable coverage noticePreventive screening services (non-grandfathered plans)