Premera Medicare Member Advisory Council Application

Thank you for your interest in improving the Premera Medicare member experience.

Please complete and submit the application:
Submitting this form does not ensure Member Advisory Council assignment. Premera Blue Cross will select members based on whether the applicant lives in the regional board area, diversity, and representation of other members.

If returning by mail, please use the provided pre-paid envelope or return to the following address:

Premera Blue Cross
PO Box 327, MS 339
Seattle, WA 98111

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Premera Blue Cross complies with applicable Federal civil rights laws (.pdf) and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

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© 2023 Premera Blue Cross is an HMO plan with a Medicare contract. Enrollment in these plans depends on contract renewal. On behalf of Premera Blue Cross, the Silver& Program is provided by American Specialty Healthy Fitness, Inc., (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver& is a federally registered trademark of ASH and used with permission herein. For accommodations of persons with special needs at meetings call For accommodations of persons
with special needs at meetings call 888-850-8526 (TTY/TDD: 711), April 1–September 30, Monday–Friday, 8 a.m.–8 p.m. and October 1–March 31, 7 days a week, 8 a.m.–8 p.m.

Y0134_PBC3000_C | 055122 (02-06-2023)