Premera Medicare Supplement Plan G Enrollment Form (Form B) 2021

Use this form to enroll in Medicare Supplemental Plan G administered by Premera.

Form

Request for Treatment as an Assistance Eligible Individual (PEBB)

To apply for a COBRA premium subsidy under the American Rescue Plan Act (ARPA) of 2021, submit this form within 60 days of the date on the enclosed letter. If you do not submit the form by the required due date, you may lose your right to receive the premium subsidy.

Form

Request for Treatment as an Assistance Eligible Individual (SEBB)

To apply for a COBRA premium subsidy under the American Rescue Plan Act (ARPA) of 2021, submit this form within 60 days of the date on the letter you received. If you do not submit the form by the required due date, you may lose your right to receive the premium subsidy.

Form