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All of the forms listed below are in PDF format which allows you to view them electronically on most computers. The Adobe Acrobat reader is required to view and print PDF files. If you do not have the reader, click here to download free of charge.

Applications

  • Click Here for free online quotes, to compare plan rate prices and benefits side-by-side, and apply for ACHIA insurance online.

  • Click Here for fillable application. Email completed application to membersupport@benefitmanagementllc.com.
    *  Please note that all Eligibility requirements must be met and the policy has Pre-Existing Condition Limitation

    Pre-Existing Condition Limitation: The policy will not cover expenses incurred during the first 6 months after its effective date for a preexisting condition. The plan will pay only for expenses incurred after such 6-month period. However, if you had coverage under another medical plan or policy ("prior plan") which was involuntarily terminated and you apply for coverage under this policy within 31 days after such involuntary termination from coverage under the "prior plan", the limitation to a preexisting condition will apply only for a period of time equal to 6 months less the time you were covered under the "prior plan".


  • Alaska Brochure
  • Authorization Agreement For Preauthorized Payments
  • Authorization for Release of Protected Health Information Form

2020 Premiums

Policies

Non-Medicare Plans

Medicare Plans

Schedule of Benefits

Pharmacy


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