Employer Forms

Proposals

• Request for rates
• Census template

Pre-Renewal

• Group size certification

New groups

Completed enrollment materials must be received at Premera for new groups by the 20th of the month to ensure eligibility by the plan start date.

• 2025 Small group master application
• 2025 Small group benefit selection worksheet
• 2024 Small group master application
• 2024 Small group benefit selection worksheet
• Member enrollment and change application
• Enrollment spreadsheet (for groups with 10 or more enrolled employees)
• Other coverage questionnaire

Send completed enrollment materials to AKPBCSmallGrpSS@PREMERA.com.

Renewing groups (2+ employees enrolled)

No action is necessary unless plan or group information changes are requested. Send change requests to AKPBCSmallGrpSS@premera.com and your designated account team no later than the 10^th of the month prior to the group’s renewal date by completing the group verification report and/or benefit selection worksheet.

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

New groups

Completed enrollment 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 plan start date.

Required documents

• Fully insured group master application
• Self-funded group master application
• Circled, signed and dated rate exhibits to acknowledge your group's plan choice(s). For self-funded groups, this includes the admin and stop loss exhibits.
• Enrollment spreadsheet
• Member enrollment and change application
• Other coverage questionnaire

Return completed enrollment materials to Senior Sales Manager Bradley.Olson@premera.com and Implementation Account Specialist Kayla.Koeckritz@premera.com.

Note: Additional forms will be provided for self-funded and Optiflex funding arrangements.

Renewing groups

Completed renewal documents and written confirmation must be received at Premera well in advance of the first of the month to ensure eligibility and receipt of ID cards by the group's renewal date.

Required documents:

• Group verification report (provided by Premera with group's renewal proposal)
• Circled, signed and dated rate exhibit(s) to acknowledge group’s plan choice(s). For self-funded groups, this includes the admin and stop loss exhibits.

Return completed renewal documents to your designated Account Manager and Implementation Account Specialist.

Note: Additional forms will be provided for any groups moving to self-funded or Optiflex funding arrangements.

Medicare Secondary Payer (MSP) - this form is 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 non-creditable coverage notice

This section provides forms for Express Scripts home delivery, prescription drug reimbursement, and other pharmacy-related forms.

Health, allergy, and medication questionnaire
Pharmacy mail-order form
Prescription drug reimbursement
Prescription drug reimbursement Form (for Alyeska Medical Retirees)
Secondary insurance drug claim

By the 1st of each month:

Completed enrollment/renewal materials for new/renewing groups must be received at Premera for HRA and HSA products for groups beginning/renewing coverage on the 1st of the following month to ensure eligibility is active on the start date.

Use these forms to enroll or renew your group into a personal funding account, such as an FSA, HRA, or HSA.

• Personal funding account enrollment and change application
• Personal funding account setup form - small groups
• Personal funding account setup form - large groups
• Funding Account ACH Authorization
• HSA Account Closure form
• HSA Designation of Beneficiary form
• HSA Trustee to Trustee Transfer form - small groups - up to 50
• Funding Account Employer Admin Guide – small groups
• Funding Account Employer Admin Guide - large groups

This section includes release of information forms.

• Summary Health Info Authorization for Self-Funded PBCAK
• Summary Health Info Authorization for Insured Groups PBCAK
• Authorization for release of psychotherapy notes
• Disclosure accounting request
• Information release form - Give someone permission to obtain and discuss personal and health information, including sensitive information such as substance abuse, reproductive health, and mental health. Members can be authorized to see sensitive information on Premera.com or their personal funding account.
• Non-disclosure request
• Request for amendment of records
• Request for inspection of records

Check this section for other frequently used forms.

• Affidavit of domestic partnership
• Claim form
• Deductible credit form
• Request for certification of disabled dependent
• Waiver of coverage
• Member enrollment and change application