EA Forms Last Audited: 1/11/2014

Premera Blue Cross - WEA Forms

Form Number

Revision Date

Form Name

(Links to Plan Source Library)

Internal Use
012880 8/12 WEA Select Enrollment and Change Application RA IA
017316 11/07 Other Coverage Questionnaire Enrollment EA  
BST-8755 04/08 Claim Form
Plans 1-4, Foundation, HealthPlus
C100177 9/12 Prescription Drug Reimbursement EA  
HDLG158 9/12 Medco By Mail Order Form EA  
001300 8/07 COBRA Continuation of Coverage RA  
008116 12/09 Termination of Domestic Partnership   RA  
GZE-W-138 7/09 Enrollment Form for Group Life Insurance RA  
005361 1/12 Authorization for Release of Health Care Information and Records EA  
N13-04-086 N/A BlueCard Worldwide International Claim Form RA  
008759 8/2004 COBRA Application RA  
Link directly to the forms section of the Premera website



Please be advised that the forms in the PlanSource Library are only as current as the forms on the carrier’s web sites.  More and more carriers are requiring a user ID and password to access the forms section of their site, so it may delay PlanSource access to updated forms.  To access the most up to date forms, users may need to register with the carrier to obtain a login. 


Please note:  Any form in the PlanSource Library that is coded "RA" means that we are unable to locate the form on the carrier's website.  You may need to contact your carrier representative or broker to obtain the most current form.

If you can't find the form that you're looking for, please contact your insurance broker or HR Administrator.