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Medicare Plan Documents and Forms

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Year Links
2020 Alaska Medicare Supplement Enrollment Application MedSupp Enrollment Form Aleutians East, Aleutians West, Anchorage, Bethel, Bristol Bay, Denali, Dillingham, Fairbanks North Star, Haines, Hoonah Angoon, Juneau, Kenai Peninsula, Ketchikan Gateway, Kodiak Island, Kusilvak, Lake And Peninsula, Matanuska Susitna, Nome, North Slope, Northwest Arctic, Petersburg, Prince Of Wales Hyder, Sitka, Skagway, Southeast Fairbanks, Valdez Cordova, Wrangell, Yakutat, Yukon Koyukuk 2020
2020 Medicare Supplement outline of coverage MedSupp Outline of Coverage "OOC" Aleutians East, Aleutians West, Anchorage, Bethel, Bristol Bay, Denali, Dillingham, Fairbanks North Star, Haines, Hoonah Angoon, Juneau, Kenai Peninsula, Ketchikan Gateway, Kodiak Island, Kusilvak, Lake And Peninsula, Matanuska Susitna, Nome, North Slope, Northwest Arctic, Petersburg, Prince Of Wales Hyder, Sitka, Skagway, Southeast Fairbanks, Valdez Cordova, Wrangell, Yakutat, Yukon Koyukuk 2020
Choosing a Medigap Policy MedSupp Choosing a Medigap Policy Aleutians East, Aleutians West, Anchorage, Bethel, Bristol Bay, Denali, Dillingham, Fairbanks North Star, Haines, Hoonah Angoon, Juneau, Kenai Peninsula, Ketchikan Gateway, Kodiak Island, Kusilvak, Lake And Peninsula, Matanuska Susitna, Nome, North Slope, Northwest Arctic, Petersburg, Prince Of Wales Hyder, Sitka, Skagway, Southeast Fairbanks, Valdez Cordova, Wrangell, Yakutat, Yukon Koyukuk 2020
Automatic Funds Transfer Authorization MedSupp Automatic Payment Option(APO)/Electronic Fund Transfer (EFT) Aleutians East, Aleutians West, Anchorage, Bethel, Bristol Bay, Denali, Dillingham, Fairbanks North Star, Haines, Hoonah Angoon, Juneau, Kenai Peninsula, Ketchikan Gateway, Kodiak Island, Kusilvak, Lake And Peninsula, Matanuska Susitna, Nome, North Slope, Northwest Arctic, Petersburg, Prince Of Wales Hyder, Sitka, Skagway, Southeast Fairbanks, Valdez Cordova, Wrangell, Yakutat, Yukon Koyukuk 2020
Medicare & You MedSupp Medicare & You Aleutians East, Aleutians West, Anchorage, Bethel, Bristol Bay, Denali, Dillingham, Fairbanks North Star, Haines, Hoonah Angoon, Juneau, Kenai Peninsula, Ketchikan Gateway, Kodiak Island, Kusilvak, Lake And Peninsula, Matanuska Susitna, Nome, North Slope, Northwest Arctic, Petersburg, Prince Of Wales Hyder, Sitka, Skagway, Southeast Fairbanks, Valdez Cordova, Wrangell, Yakutat, Yukon Koyukuk 2020
Medicare Supplement Replacement Notice MedSupp Notice of replacement Aleutians East, Aleutians West, Anchorage, Bethel, Bristol Bay, Denali, Dillingham, Fairbanks North Star, Haines, Hoonah Angoon, Juneau, Kenai Peninsula, Ketchikan Gateway, Kodiak Island, Kusilvak, Lake And Peninsula, Matanuska Susitna, Nome, North Slope, Northwest Arctic, Petersburg, Prince Of Wales Hyder, Sitka, Skagway, Southeast Fairbanks, Valdez Cordova, Wrangell, Yakutat, Yukon Koyukuk 2020
Multi-Language Intrepreter Services MedSupp Multi-Language Intreperter Aleutians East, Aleutians West, Anchorage, Bethel, Bristol Bay, Denali, Dillingham, Fairbanks North Star, Haines, Hoonah Angoon, Juneau, Kenai Peninsula, Ketchikan Gateway, Kodiak Island, Kusilvak, Lake And Peninsula, Matanuska Susitna, Nome, North Slope, Northwest Arctic, Petersburg, Prince Of Wales Hyder, Sitka, Skagway, Southeast Fairbanks, Valdez Cordova, Wrangell, Yakutat, Yukon Koyukuk 2020
2021 - MedSupp - Choosing a Medigap Policy-All MedSupp Choosing a Medigap Policy do-not-filter 2021
2021 - MedSupp - Medicare & You-All MedSupp, MedSupp Medicare & You do-not-filter 2021
2021 Outline of Coverage do-not-filter Outline of Coverage "OOC" do-not-filter 2021
2021 Automatic Funds Transfer Authorization do-not-filter Automatic Funds Transfer Authorization do-not-filter 2021
2021 Medicare Supplement Replacement Notice do-not-filter Medicare Supplement Replacement Notice do-not-filter 2021
2021 Multi-Language Interpreter Services do-not-filter Multi-Language Interpreter Services do-not-filter 2021

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).