Forms & publications

A summary of what the SEBB Premera High PPO plan covers and what it costs.

This benefits book describes what is covered as a SEBB member under Premera HMO plan, including medical services and prescription drugs, as well as specific services not covered by the plan. Finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays. It also includes how to request an appeal, submit a claim, and how Medicare works with your plan.

A summary of what the SEBB Premera HMO plan covers and what it costs.

Preauthorization requirements for Premera Blue Cross. Preauthorization is when you seek approval from your health plan for coverage of specific services, supplies, or drugs before receiving them. Some services or treatments (except emergencies) may require preauthorization before the plan pays for them. These criteria do not imply or guarantee approval. Please check with your plan to ensure coverage. Preauthorization requirements are only valid for the month published. They may have changed from previous months and may change in future months.

This benefits book describes what is covered as a SEBB member under Premera Standard PPO plan, including medical services and prescription drugs, as well as specific services not covered by the plan. Finding preferred providers and how much you’ll pay, including deductibles, coinsurance, and copays. It also includes how to request an appeal, submit a claim, and how Medicare works with your plan.

A summary of what the SEBB Premera Standard PPO plan covers and what it costs.

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by age.

Certificate of coverage for Premera Medicare Supplement Plan F, by reason of disability.

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

Certificate of coverage for Premera Medicare Supplement Plan G for those eligible by age.