Forms

  • Enrollment

    Medical/Vision Enrollment - Please see your school district administrator.

    Other Coverage Questionnaire - If you or your dependents are covered by a medical and/or vision plan other than a WEA Select plan, fill out this form and return it to your school district administrator.

    UnumProvident Life Card - Please see your school district administrator.

    COBRA rates and applications - Please see your school district administrator.

  • Using Your Plan

    Claim form for WEA Medical Plans and Premera Vision Plans A & D - If you use a non-contracted provider, you may have to pay for services upfront and submit the claim to Premera for reimbursement up to the allowable charge.

    Claim form for Vision Plans B, C, E and F - Log in to VSP’s site to find claim forms and benefit information.

    Leave of Absence - Please see your school district administrator.

    Express Scripts Order Form - Use this form to order new maintenance prescriptions or refills.

    Prescription Drug Reimbursement Form - Fill out this claim form if you have used a non-contracted pharmacy or you did not have your ID card and had to pay the full cost of the prescription.

    Secondary Prescription Drug Reimbursement Form - Use this form only if you have other coverage that is primary for prescription drugs and more than one drug claim to submit. (Hint: you may submit other coverage for a single drug claim on this form or the Prescription Drug Reimbursement Form, above—you do not need to fill out both.)

    Declaration of Domestic Partnership - For use with WEA Select Medical and Vision plans.

    Request for Certification of Disabled Dependent - Use this form if you are requesting continued coverage for an overage dependent child due to physical or developmental handicap. Please refer to your benefit book for eligibility requirements.

    Incident Questionnaire - Use after sustaining an injury or being involved in an accident.

    Appeal Process for WEA Enrollees - You will find descriptions of the Premera appeals process in this document. This information is also contained in your benefit book.

    Authorization for Appeals - This form allows Premera to receive healthcare information pertaining to the appeal.

    Appeal Request Form - Use this form to request an appeal.

    Healthcare Info/Records Release - Use this form to authorize us to share the personal information you describe with the person or entity you name.

    Healthcare Information Non-Disclosure Request - Use this form to tell us not to share your personal information with certain parties. For more on our privacy practices, click on “Privacy” below, on this web page.