Forms and information

Forms

Call us at 844-427-8501 if you need help with these forms.

• Appeal filing form
• Authorization for release of protected health information
• Continuity of care request form
• Late self-payment request/appeal form
• Life insurance beneficiary form
• Mail order pharmacy form
• Prescription reimbursement claim form
• 1095-B tax form

Health Connect Newsletter

• January 2023

Information

Get to know your benefits. That will help you know what is available to you. To find out about your benefits call us at 844-427-8501.

• Are you using your new Alaska Plan ID cards?
• Let us help you get the most out of your health benefits!

• Participant Guide

  Download a copy of your Participant Guide.

  • Gold Plan
  • Silver Plan
  • Bronze Plan

• Summary Annual Report (SAR)

  • Summary Annual Report

• Summary of Benefits and Coverage (SBC)

  Download a copy of your Summary of Benefits and Coverage (SBC). It gives you a quick outline of some of your benefits and costs.

  2023

  • Gold Plan
  • Silver Plan
  • Bronze Plan

• Benefits at a Glance

  View your Benefits at a Glance:

  2022

  • Gold Plan
  • Silver Plan
  • Bronze Plan

• Summary Plan Description (SPD)

  View your Summary Plan Description (SPD). It explains all of your benefits.

• Summary of Material Modifications (SMM)

  After each SPD is published, certain changes may have been made to your benefits. These changes are reflected in a Summary of Material Modifications (SMM).

• Your Rights and Protections Against Surprise Medical Bills

  When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory (outpatient) surgical center, you are protected from “surprise billing” or “balance billing.” More information