Icon of a clipboard outlined in blue with three lines in the middle depicted on a blue circle

Forms & Documents

Common forms

Medical and Vision Claim Reimbursement Form

Dental Claim Reimbursement Payment Consideration Form

For members

Appoint a representative

If you would like someone else to act on your behalf, like a family member or provider, fill out and submit the Appointment of Representative Form (.pdf).

Mail to:

Premera Medicare Advantage Plans
PO Box 21481
Eagan, MN 55121

Fax: 800-390-9656

File a claim

Dental

Dental Claim Reimbursement Payment Consideration Form

Medical, Vision, Part B Vaccines & Durable Medical Equipment (DME)

Medical and Vision Claim Reimbursement Form

Prescriptions & Part D Vaccines

Medicare Part D Prescription Claim Form

Have you had care while traveling internationally? If so, you will need the International Claims Form. Log in at BCBSA Global Core. Click here.

Provider directories

2024 Directories

Provider and Pharmacy directory

Dental directory

Vaccine information

Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Customer Service for more information.

Vaccines Covered By Medicare Part B

Medicare Part B covers four important vaccines as part of its preventive care benefits. All this information is included in your EOC (Evidence of coverage) documents, there is no coinsurance, copayment, or deductible for these vaccines.

Covered vaccines include the following:

Flu vaccine: once each flu season in the fall and winter, with additional flu shots if medically necessary
Hepatitis B vaccine: if you are at high or intermediate risk of getting Hepatitis B
Pneumonia vaccine
COVID-19 Vaccine

Vaccines Covered By Medicare Part D

Medicare Part D covers all commercially available vaccines needed to prevent illness.

Vaccines covered by Part D include the following:

Shingles vaccine: One-time vaccine given in two shots over two to six months
Tdap vaccine : (tetanus, diphtheria and pertussis/whooping cough): One shot if you’ve never been vaccinated, and a booster every ten years

Do I Have to Pay For Vaccines with Medicare?

You pay nothing for vaccines covered by Part B – flu, pneumonia, covid-19 and Hepatitis B – as long as your provider accepts Medicare.

Your cost for vaccines covered by Part D will depend on your specific plan and location of administration. You pay a copay if it is administered in the pharmacy. If you do receive it in the doctor’s office you will pay for the whole cost of the vaccine and the administration, you can submit a claim to be reimbursed.

For requests for reimbursement of prescription drugs and/or Part D vaccines, please mail your request for payment together with any bills or paid receipts to us at this address:

CVS/Caremark - Medicare Part D Paper Claim
PO Box 52066
Phoenix, AZ 85072-206

Part D vaccine claim form

Medicare Part D Prescription Claim Form

Part B vaccine claim form

Medical and Vision Claim Reimbursement Form

Where Can I Get Vaccines I Need?

You can get most vaccines at a pharmacy, doctor’s office, clinic or community health center. Talk with your doctor about what vaccines you may need. Your doctor or Part D plan provider can also help you understand whether your cost will be affected by where you go to get the vaccines that your doctor recommends.

Part D coverage and support

File an appeal

You, your doctor, or your representative can file an appeal online using the following form.

Drug Coverage Redetermination Form

You can also file an appeal by completing the following form and faxing or mailing it to us.

Request for Redetermination of Medicare Prescription Drug Denial

Extra help

The government subsidizes prescription drug costs for members with limited incomes. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs.

For more information about this extra help, review the Low Income Subsidy (LIS) Premium Summary Table. You can also contact your local Social Security office, or call 800-MEDICARE (800-633-4227) 24 hours a day, 7 days a week. TTY/TTD users should call 877-486-2048 (TTY/TDD: 711).

2024 LIS Premium Summary Table (.pdf)