Make Sure You’re Covered

  • Don’t be surprised by a medical bill you weren’t expecting

    About prior authorization

    Did you know that many services and procedures require an OK for coverage from Premera before you get them? This is called prior authorization, and it helps you:

    • Find out if you’re covered by your benefits before you have your scheduled procedure
    • Save money and avoid extra costs
    • Get an estimate of your out-of-pocket costs before you go
    • Avoid inappropriate or unnecessary medical treatment

    Premera uses a team of experienced doctors, nurses, and healthcare analysts to determine if a medical procedure is appropriate and supported by clinical best practices.

    Doctors who are in the Premera network can request prior authorization for you

    Healthcare providers who are in the Premera network are familiar with the process for getting prior authorization. They can contact Premera on your behalf. In-network doctors have all of the medical information needed to ask that your medical service be reviewed and approved for coverage. You should always ask your healthcare provider about requesting prior authorization before you schedule a service or procedure. 

    What happens if your doctor doesn’t request prior authorization

    If your doctor gives you a service that requires prior authorization without requesting one, you may have to pay part or all of the cost, above your usual cost shares. For complete information about your plan's medical benefits and prior authorization requirements, read or download your benefit booklet.

    To avoid extra costs always ask your healthcare provider to request prior authorization before you have a planned medical service. 

    The list below shows some services and procedures that require prior authorization. 

    Some services that require prior authorization*

    • Planned admission into hospitals or skilled nursing facilities
    • Some inpatient surgeries
    • Non-emergency or ambulance transport
    • Advanced imaging, such as MRIs, CT scans, and cardiac imaging
    • Transplant and donor services
    • Some planned outpatient procedures and surgeries
    • Some injectable injectable medications you get in a healthcare provider’s office
    • Prosthetics and orthotics other than foot orthotics or orthopedic shoes
    • Reconstructive surgery
    • Homemedical equipment costing $500 or more
    • Some drug treatments

    Please note: If you have a prescription plan benefit, some drugs must be approved for coverage through our Pharmacy Prior Authorization Program. Learn more about drugs requiring approval.

    *This is not a complete list and shows only some of the services and drug treatments that require prior authorization. Your doctor has the most current list and medical information needed to request a prior authorization on your behalf.

    Services that do not require prior authorization

    • Hospital admission for childbirth and newborn care
    • Emergency admission to hospital
    • Office visits to a primary care doctor, family doctor, or specialist

    Questions?

    Call Customer Service at the number on your Premera member card.