If you would like someone else to act on your behalf, like a family member or provider, fill out and submit the Appointment of Representative Form (.pdf).

Mail to:

Premera Medicare Advantage Plans
PO Box 262527
Plano, TX 75026

Fax: 800-390-9656

If you would like to have premium payments automatically deducted from your checking or savings account, fill out and submit the Automatic Funds Transfer Authorization (.pdf). Submit one form for each applicant and allow up to 60 days to process your request.

Mail to:

Premera Medicare Advantage Plans
PO Box 262548
Plano, TX 75026

Fax: 800-390-9656

If you are already enrolled in a Medicare Advantage plan, you can only change your plan selection during the Open Enrollment Period (OEP), or during a qualifying event (known as a Special Enrollment Period). For more information on eligibility and enrollment periods, refer to our Medicare Guidebook (.pdf).

• 2023 Plan Change Form

If you would like to transfer the rights and responsibilities of a producer to a new producer, please fill out the Producer of Record Change Form (.pdf) and return it to your new producer. This form allows the designated producer to get information about you and your Premera Blue Cross Medicare Advantage or Medicare Supplement Plan.

Dental

• Dental Claim Reimbursement Payment Consideration Form

Medical & Vision

• Medical and Vision Claim Reimbursement Form

Prescriptions

• Medicare Part D Prescription Claim Form

Mail-order prescriptions

Get your prescriptions delivered to your home using our mail-order pharmacy home delivery services.

• CVS Caremark Prescription Mail-Order Form

Over the counter

Premera Blue Cross Medicare Advantage members receive up to a $50 quarterly benefit to order generic over-the-counter (OTC) health and wellness products through OTC Health Solutions.

Order from a list of approved OTC items as seen in the OTC Health Solutions Catalog below, and OTC Health Solutions will mail them directly to your home address.

To place an order, you can:

• Call OTC Health Solutions at 888-628-2770 (TTY/TDD: 711)
• Visit cvs.com/otchs/premera
• Visit any OTC Health Solutions-enabled CVS Pharmacy

• 2023 OTC Health Solutions Catalog
• 2023 OTC Health Solutions FAQ

Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Customer Service for more information.

Vaccines Covered By Medicare Part B

Medicare Part B covers four important vaccines as part of its preventive care benefits. All this information is included in your EOC (Evidence of coverage) documents, there is no coinsurance, copayment, or deductible for these vaccines.

Covered vaccines include the following:

• Flu vaccine: Annual vaccine given in one shot before or during flu season, usually November through April
• Hepatitis B vaccine: for people who are medium to high risk, including people with diabetes
• Pneumonia vaccine
• COVID-19 Vaccine

Vaccines Covered By Medicare Part D

Medicare Part D covers all commercially available vaccines needed to prevent illness.

Vaccines covered by Part D include the following:

• Shingles vaccine: One-time vaccine given in two shots over two to six months
• Tdap vaccine : (tetanus, diphtheria and pertussis/whooping cough): One shot if you’ve never been vaccinated, and a booster every ten years

Do I Have to Pay For Vaccines with Medicare?

You pay nothing for vaccines covered by Part B – flu, pneumonia, covid-19 and Hepatitis B – as long as your provider accepts Medicare.

Your cost for vaccines covered by Part D will depend on your specific plan and location of administration. You pay a copay if it is administered in the pharmacy. If you do receive it in the doctor’s office you will pay for the whole cost of the vaccine and the administration, you can submit a claim to be reimbursed.

For requests for reimbursement of prescription drugs and/or Part D vaccines, please mail your request for payment together with any bills or paid receipts to us at this address:

CVS/Caremark - Medicare Part D Paper Claim
PO Box 52066
Phoenix, AZ 85072-2066

• Medical and Vision Claim Reimbursement Form

Where Can I Get Vaccines I Need?

You can get most vaccines at a pharmacy, doctor’s office, clinic or community health center. Talk with your doctor about what vaccines you may need. Your doctor or Part D plan provider can also help you understand whether your cost will be affected by where you go to get the vaccines that your doctor recommends.

Request a coverage determination

You, your prescriber, or your representative may ask for a coverage decision online using the following form.

Medicare Coverage Determination Form

You can also request a coverage determination by completing the following form and faxing or mailing it to us.

• Request for Medicare Prescription Drug Coverage Determination

File an appeal

You, your doctor, or your representative can file an appeal online using the following form.

Drug Coverage Redetermination Form

You can also file an appeal by completing the following form and faxing or mailing it to us.

• Request for Redetermination of Medicare Prescription Drug Denial

Extra help

The government subsidizes prescription drug costs for members with limited incomes. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs.

For more information about this extra help, review the Low Income Subsidy (LIS) Premium Summary Table. You can also contact your local Social Security office, or call 800-MEDICARE (800-633-4227), 24 hours a day, 7 days a week. TTY/TTD users should call 877-486-2048 (TTY/TDD: 711).

• 2023 LIS Premium Summary Table (.pdf)

Prior authorization

You may require prior authorization before a drug prescription can be filled. Review the prior authorization criteria below to see if your drug is affected.

If you are impacted, you can ask Premera for a coverage determination by submitting the form below.

• 2023 Prior Authorization Criteria
• Prior Authorization Form

Step therapy

Step therapy is a type of prior authorization for drugs that begins medication for a medical condition with the most preferred drug therapy and progresses to other therapies only if necessary.

• 2023 Step Therapy Criteria

Information release

Give permission to obtain and discuss your personal and health information.

• Information Release Form

Change of records

Change your official personal information record that we keep.

• Change of Records Form

Authorization of notes

Allow access to notes made by medical professionals providing psychiatric or psychological services.

• Authorization of Psychotherapy Notes

Record of disclosure

Request a record of how we disclose information about you for reasons other than our normal business functions.

• Request Records of Disclosure Form

Copy of records

Request certain records we keep that contain your personal information.

• Request Copy of Records

Premera Blue Cross Medicare Advantage reviews all medical policies and criteria annually.

• February 2023
• March 2023
• April 2023
• June 2023
• July 2023
• August 2023

Use the Medicare Complaint form for problems related to quality of care, waiting times, and customer service you receive.

For problems about decisions related to benefits, coverage, or payment, you must use the process for coverage decisions and appeals.

Ending your membership in our plan may be voluntary (your own choice) or involuntary (not your own choice). Find more information here (.pdf) on what to do if one of these situations arises.

If your membership ends involuntarily, you have the right to make a complaint. We will tell you about our reasons in writing and explain how you may file a complaint against us.