Forms & Documents
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).
Premera Medicare Advantage Plans
PO Box 262527
Plano, TX 75026
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.
Premera Medicare Advantage Plans
PO Box 262548
Plano, TX 75026
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).
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.
Medical & Vision
Get your prescriptions delivered to your home using our mail-order pharmacy home delivery services.
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
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
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.
You can also request a coverage determination by completing the following form and faxing or mailing it to us.
File an appeal
You, your doctor, or your representative can file an appeal online using the following form.
You can also file an appeal by completing the following form and faxing or mailing it to us.
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).
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.
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.
Give permission to obtain and discuss your personal and health information.
Change of records
Change your official personal information record that we keep.
Authorization of notes
Allow access to notes made by medical professionals providing psychiatric or psychological services.
Record of disclosure
Request a record of how we disclose information about you for reasons other than our normal business functions.
Copy of records
Request certain records we keep that contain your personal information.
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.
Medicare Advantage plan documents
Enroll in a new plan
You can enroll in a Medicare Advantage Plan when you first become eligible for Medicare, or during certain times of the year. For more information on eligibility and enrollment, refer to our Medicare Guidebook (.pdf).
2023 Enrollment forms and documents
- 2023 Pre-Enrollment Checklist
- 2023 Enrollment Form
- 2023 Plan Change Form
- 2023 Summary of Benefits
- 2023 Scope of Appointment Form
Premera Medicare Advantage Star Ratings
The Medicare Star Rating is based on quality, service, and member satisfaction.
Learn about Medicare plans offered in your area.