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Medicare Plan Documents and Forms

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Year Links
2018 Summary of Benefits do-not-filter Summary of Benefits (PDF) do-not-filter 2018
Choosing a Medigap Policy do-not-filter Choosing a Medigap Policy do-not-filter 2018
Medicare & You do-not-filter Evidence of Coverage (PDF) do-not-filter 2018
Replacement of Medicare Supplement or Medicare Advantage Coverage do-not-filter Notice of replacement do-not-filter 2018
2018 Medicare Supplement Outline of Coverage do-not-filter Outline of Coverage "OOC" do-not-filter 2018
Medicare complaint form do-not-filter Complaint King, Pierce, Snohomish, Spokane, Thurston 2018
2018 Medicare Advantage Optional Dental Plan Enrollment Form do-not-filter Enrollment form King, Pierce, Snohomish, Spokane, Thurston 2018
The Rising Cost of Healthcare Fraud do-not-filter Medicare information King, Snohomish, Spokane, Thurston 2018
2018 Evidence of Coverage – Premera Blue Cross Medicare Advantage (HMO) do-not-filter Evidence of Coverage (PDF) King, Pierce, Snohomish, Spokane, Thurston 2018
2018 Evidence of Coverage – Premera Blue Cross Medicare Advantage Classic (HMO) do-not-filter Evidence of Coverage (PDF) King, Pierce, Snohomish, Thurston 2018
2018 Evidence of Coverage – Premera Blue Cross Medicare Advantage Classic Plus (HMO) do-not-filter Evidence of Coverage (PDF) King, Pierce, Snohomish, Thurston 2018
2018 Annual Notice of Change – Premera Blue Cross Medicare Advantage Classic (HMO) do-not-filter Annual Notice of Change King, Pierce, Snohomish, Thurston 2018
2018 Annual Notice of Change Premera Blue Cross Medicare Advantage Classic Plus (HMO) do-not-filter Annual Notice of Change King, Pierce, Snohomish, Thurston 2018
Diabetic Glucose Monitors and Supplies 2018 Preferred Brands and Manufacturers do-not-filter Medical Equipment flyer King, Pierce, Snohomish, Spokane, Thurston 2018
Find a Doctor do-not-filter Find a Doctor King, Pierce, Snohomish, Spokane, Thurston 2018
2018 Medicare Advantage Drug List (Formulary) do-not-filter Drug List (Formulary) (PDF) King, Pierce, Snohomish, Spokane, Thurston 2018
2018 Medicare Advantage Low Income Subsidy Premium Summary Table for Those Receiving Extra Help do-not-filter Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) King, Pierce, Snohomish, Spokane, Thurston 2018
Medicare Advantage Prescription Drug Prior Authorization Request Form do-not-filter Medication approval King, Pierce, Snohomish, Spokane, Thurston 2018
2018 Medicare Advantage Prior Authorization Criteria do-not-filter Medication approval King, Pierce, Snohomish, Spokane, Thurston 2018
2018 Medicare Advantage Part D Step Therapy Criteria do-not-filter Step therapy King, Pierce, Snohomish, Spokane, Thurston 2018
2018 Medicare Advantage Pharmacy Directory do-not-filter Find a Doctor King, Pierce, Snohomish, Spokane, Thurston 2018
2018 Medicare Advantage Personal Medication List do-not-filter Drug Transition Policy (PDF) do-not-filter 2018
2018 Annual Notice of Change – Premera Blue Cross Medicare Advantage (HMO) do-not-filter Annual Notice of Change King, Pierce, Snohomish, Spokane, Thurston 2018
Medicare Advantage Mail Order Pharmacy do-not-filter Pharmacy Directory do-not-filter 2018
Medicare Advantage Request Reimbursement for Prescription Drugs do-not-filter Pharmacy Directory do-not-filter 2018
2018 Medicare Advantage Enrollment Application - Western Washington do-not-filter Enrollment form King, Pierce, Snohomish, Thurston 2018
2018 Evidence of Coverage – Premera Blue Cross Medicare Advantage Total Health (HMO) do-not-filter Evidence of Coverage (PDF) Spokane 2018
2018 Medicare Star Ratings do-not-filter Plan Rating (PDF) do-not-filter 2018
2018 Medicare Advantage Enrollment Application - Spokane do-not-filter Enrollment form Spokane 2018
2018 Summary of Benefits -- Medicare Advantage Total Health (HMO) do-not-filter Summary of Benefits (PDF) Spokane 2018
2018 Medicare Advantage Drug Transition Policy MAPD Drug Transition Policy (PDF) do-not-filter 2018
2018 Summary of Benefits -- Medicare Advantage (HMO) do-not-filter Summary of Benefits (PDF) King, Pierce, Snohomish, Spokane, Thurston 2018
2018 Summary of Benefits -- Medicare Advantage Classic (HMO) do-not-filter Summary of Benefits (PDF) King, Pierce, Snohomish, Thurston 2018
2018 Summary of Benefits -- Medicare Advantage Classic Plus (HMO) do-not-filter Summary of Benefits (PDF) King, Pierce, Snohomish, Thurston 2018
2018 Summary of Benefits -- Medicare Advantage - Western Washington MAPD Summary of Benefits (PDF) do-not-filter 2018
2018 Summary of Benefits -- Medicare Advantage - Spokane MAPD Summary of Benefits (PDF) Spokane 2018
2019 Medicare Star Ratings – HMO, Core (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) do-not-filter Plan Rating (PDF) do-not-filter 2019
Medicare Advantage Automatic Funds Transfer Authorization do-not-filter Payment do-not-filter 2019
2018 Medicare Advantage Plan Selection Form - Spokane do-not-filter Plan selection do-not-filter 2018
2018 Medicare Advantage Plan Selection Form - Western Washington do-not-filter Plan selection do-not-filter 2018
2018 Medicare Advantage Drug List (Formulary) Negative Changes do-not-filter Drug List (Formulary) (PDF) King, Pierce, Snohomish, Spokane, Thurston 2018
2019 Medicare Advantage Star Ratings – Alpine (HMO), Charter + Rx (HMO), Peak + Rx (HMO), Sound + Rx (HMO) do-not-filter Plan Rating (PDF) do-not-filter 2019
2018 Medicare Supplement Enrollment Application do-not-filter Enrollment form do-not-filter 2018
2019 Annual Notice of Change – Premera Blue Cross Medicare Advantage (HMO) do-not-filter Annual Notice of Change do-not-filter 2019
2019 Annual Notice of Change – Premera Blue Cross Medicare Advantage Classic (HMO) do-not-filter Annual Notice of Change do-not-filter 2019
2019 Annual Notice of Change – Premera Blue Cross Medicare Advantage Classic Plus (HMO) do-not-filter Annual Notice of Change do-not-filter 2019
2019 Annual Notice of Change – Premera Blue Cross Medicare Advantage Total Health (HMO) do-not-filter Annual Notice of Change do-not-filter 2019
2019 Annual Notice of Change – Premera Blue Cross Medicare Advantage Alpine (HMO) do-not-filter Annual Notice of Change do-not-filter 2019
2019 Annual Notice of Change – Premera Blue Cross Medicare Advantage Charter + Rx (HMO) do-not-filter Annual Notice of Change do-not-filter 2019
2019 Annual Notice of Change – Premera Blue Cross Medicare Advantage Peak + Rx (HMO) do-not-filter Annual Notice of Change do-not-filter 2019
2019 Annual Notice of Change – Premera Blue Cross Medicare Advantage Sound + Rx (HMO) do-not-filter Annual Notice of Change do-not-filter 2019
2019 Evidence of Coverage – Premera Blue Cross Medicare Advantage (HMO) do-not-filter Evidence of Coverage (PDF) do-not-filter 2019
2019 Evidence of Coverage – Premera Blue Cross Medicare Advantage Classic (HMO) do-not-filter Evidence of Coverage (PDF) do-not-filter 2019
2019 Evidence of Coverage – Premera Blue Cross Medicare Advantage Classic Plus (HMO) do-not-filter Evidence of Coverage (PDF) do-not-filter 2019
2019 Evidence of Coverage – Premera Blue Cross Medicare Advantage Total Health (HMO) do-not-filter Evidence of Coverage (PDF) do-not-filter 2019
2019 Evidence of Coverage – Premera Blue Cross Medicare Advantage Core (HMO) do-not-filter Evidence of Coverage (PDF) do-not-filter 2019
2019 Evidence of Coverage – Premera Blue Cross Medicare Advantage Alpine (HMO) do-not-filter Evidence of Coverage (PDF) do-not-filter 2019
2019 Evidence of Coverage – Premera Blue Cross Medicare Advantage Charter + Rx (HMO) do-not-filter Evidence of Coverage (PDF) do-not-filter 2019
2019 Evidence of Coverage – Premera Blue Cross Medicare Advantage Peak + Rx (HMO) do-not-filter Evidence of Coverage (PDF) do-not-filter 2019
2019 Evidence of Coverage – Premera Blue Cross Medicare Advantage Sound + Rx (HMO) do-not-filter Evidence of Coverage (PDF) do-not-filter 2019
2019 Medicare Advantage Diabetic Glucose Monitors and Supplies Preferred Brands and Manufacturers – HMO, Core (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) do-not-filter Medical Equipment flyer do-not-filter 2019
2019 Medicare Advantage Diabetic Glucose Monitors and Supplies Preferred Brands and Manufacturers – Alpine (HMO), Charter + Rx (HMO), Peak + Rx (HMO), Sound + Rx (HMO) do-not-filter Medical Equipment flyer do-not-filter 2019
2019 Medicare Advantage Drug List (Formulary) – HMO, Core (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) do-not-filter Drug List (Formulary) (PDF) do-not-filter 2019
2019 Medicare Advantage Drug List (Formulary) – Charter + Rx (HMO), Peak + Rx (HMO), Sound + Rx (HMO) do-not-filter Drug List (Formulary) (PDF) do-not-filter 2019
2019 Medicare Advantage Drug Transition Policy do-not-filter Drug Transition Policy (PDF) do-not-filter 2019
2019 Medicare Advantage Enrollment Application do-not-filter Enrollment form do-not-filter 2019
2019 Medicare Advantage Low Income Subsidy Premium Summary Table for Those Receiving Extra Help do-not-filter Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2019
2019 Medicare Advantage Part D Step Therapy Criteria – HMO, Core (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) do-not-filter Step therapy do-not-filter 2019
Medicare Advantage Personal Medication List do-not-filter Personal Medication List (PDF) do-not-filter 2019
2019 Medicare Advantage Pharmacy Directory do-not-filter Pharmacy Directory do-not-filter 2019
2019 Medicare Advantage Prior Authorization Criteria – HMO, Core (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) do-not-filter Prior Authorization Criteria do-not-filter 2019
2019 Medicare Advantage Prior Authorization Criteria – Charter + Rx (HMO), Peak + Rx (HMO), Sound + Rx (HMO) do-not-filter Prior Authorization Criteria do-not-filter 2019
2019 Summary of Benefits Medicare Advantage Core (HMO) – Skagit and Whatcom counties do-not-filter Summary of Benefits (PDF) do-not-filter 2019
2019 Summary of Benefits Medicare Advantage (HMO), Total Health (HMO) – Spokane and Stevens counties do-not-filter Summary of Benefits (PDF) Spokane, Stevens 2019
2019 Summary of Benefits Medicare Advantage (HMO), Classic (HMO), Classic Plus (HMO) – King, Lewis, Pierce, Snohomish, and Thurston counties do-not-filter Summary of Benefits (PDF) King, Lewis, Pierce, Snohomish, Thurston 2019
2019 Summary of Benefits Medicare Advantage Alpine (HMO), Charter + Rx (HMO) – King, Pierce, Snohomish, Thurston, and Whatcom counties do-not-filter Summary of Benefits (PDF) do-not-filter 2019
2019 Summary of Benefits Medicare Advantage Peak + Rx (HMO), Sound + Rx (HMO) – King, Pierce, Snohomish, Thurston, and Whatcom counties do-not-filter Summary of Benefits (PDF) do-not-filter 2019
Outline of Coverage "OOC" (pdf) MedSupp Outline of Coverage "OOC" do-not-filter 2019
Medicare Advantage Claim Reimbursement Form MAPD Additional Documents do-not-filter 2019
Pre-Enrollment Checklist do-not-filter Pre Enrollment Checklist do-not-filter 2019
2019 Medicare Supplement Enrollment Application do-not-filter Enrollment form do-not-filter 2019
2019 Summary of Benefits Medicare Advantage (HMO), Total Health (HMO) – Lewis County do-not-filter Summary of Benefits (PDF) Lewis 2019
2019 Medicare Advantage Drug List (Formulary) Negative Changes – HMO, Core (HMO), Classic (HMO), Classic Plus (HMO), Total Health (HMO) do-not-filter Drug List (Formulary) (PDF) King, Lewis, Pierce, Skagit, Snohomish, Spokane, Stevens, Thurston, Whatcom 2019
2019 Medicare Advantage Drug List (Formulary) Negative Changes – Peak + Rx (HMO), Sound + Rx (HMO), Charter + Rx (HMO) do-not-filter Drug List (Formulary) (PDF) King, Pierce, Snohomish, Thurston, Whatcom 2019
2019 Medicare Advantage Part D Step Therapy Criteria – Sound + Rx (HMO), Peak + Rx (HMO), Charter + Rx (HMO) do-not-filter Drug List (Formulary) (PDF) King, Pierce, Snohomish, Thurston, Whatcom 2019

© 2018 Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association serving businesses and residents of Alaska and Washington state, excluding Clark County. Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal. This information is not a complete description of benefits. Call 888-868-7767 (TTY/TDD: 711) 7 days a week, 8 a.m. to 8 p.m. for more information. To join a Premera Blue Cross Medicare Advantage Plan, you must have Medicare Part A and Part B and live in the Premera Blue Cross Medicare Advantage service area (King, Pierce, Lewis, Skagit, Snohomish, Spokane, Stevens, Thurston, and Whatcom counties in Washington). Members must select a Primary Care Provider (PCP) from the Premera Blue Cross Medicare Advantage Plans provider network. For accommodation of persons with special needs at sales meetings, call 888-868-7767 (TTY/TDD: 711), 7 days a week, 8 a.m. to 8 p.m.

H7245_H9302_PBC1701 - Last updated 2018-10-01