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Medicare Plan Documents and Forms

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Looking for a plan document or a certain form? If you know the type of document you are looking for, you may use the filters below, or you can search by keyword.

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Year Links
Choosing a Medigap Policy do-not-filter Choosing a Medigap Policy do-not-filter 2019
Find a Doctor do-not-filter Find a Doctor King, Pierce, Snohomish, Spokane, Thurston 2019
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
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
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
Medicare Supplement Automatic Funds Transfer Authorization do-not-filter Medicare Supplement Automatic Funds Transfer Adams, Asotin, Benton, Chelan, Clallam, Columbia, Cowlitz, Douglas, Ferry, Franklin, Garfield, Grant, GraysHarbor, Island, Jefferson, King, Kitsap, Kittitas, Klickitat, Lewis, Lincoln, Mason, Okanogan, Pacific, PendOreille, Pierce, SanJuan, Skagit, Skamania, Snohomish, Spokane, Stevens, Thurston, Wahkiakum, WallaWalla, Whatcom, Whitman, Yakima 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.