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*Monthly Bank Draft Discount:  You must choose the Monthly Bank Draft option during the application process to receive the discounted price. If you choose another method of payment, you will be billed at the regular price.

This application is not a guarantee that you will receive coverage. Upon approval of your application, you will receive an approval letter and a contract.
You can become a Premera Blue Cross Blue Shield of Alaska (Premera) Medicare supplement member if you:
Reside in Alaska,
Currently have both Medicare Part A and Part B, and
Don't receive Medicaid assistance other than payment of your Medicare Part B premium.

You do not need more than one Medicare supplement plan. If you currently have a Medicare supplement plan or Medicare Advantage plan (including a Medicare HMO or PPO), you cannot be enrolled unless you intend to replace your current coverage. Please complete a replacement form. If you purchase this contract, you may want to evaluate your existing health coverage and decide if you need multiple coverages.

You may be eligible for benefits under Medicaid and may not need a Medicare supplement plan. Medicaid is a public aid program for people with low income. It is not the same as Medicare.

If, after purchasing this plan, you become entitled to Medicaid, the benefits and subscription charges under your Medicare Supplement contract can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of being eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare supplement plan (or, if that is no longer available, a substantially equivalent plan) will be re-instituted if requested within 90 days of losing Medicaid eligibility.

Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement coverage and concerning medical assistance through the state Medicaid program, including benefits as a "Qualified Medicare Beneficiary" (QMB) or a "Specified Low-Income Medicare Beneficiary" (SLMB).

Except that you must provide information on diseases and disorders for which you have symptoms, please do not provide any information on any part of this application about genetic testing or genetic information, including any decision by an insurance company that is based on a genetic test or genetic information.

Plan A 021202 (06-2010); 021198 (06-2010); Plan N 021203 (06-01-2010); 021199 (06-01-2010); Plan F 021204 (06-2010); 021200 (06-2010); High Deductible Plan F 021205 (06-2010); 021201 (06-2010); Plan G 042196 (01-2018); 042195 (01-2018); High Deductible Plan G 049580 (01-2020); 049581 (01-2020).