About Individual Health Plans

Sales brochure

Health plans for individuals and families

Health plans for American Indians and Alaska Natives

Dental plans for adults - coming soon!

Plan summaries

Available directly from Premera

Preferred Plus Gold 1500

Preferred Plus Silver 3000

Preferred Plus Bronze 6350

Preferred Plus Bronze 5250 HSA

Preferred Plus Silver 3000 HSA

Plus Qualified Gold 1500

Plus Qualified Silver 2700

Plus HSA Silver 4000

Plus Qualified Bronze 5250

Plus Silver HSA 4000 + Family Dental

Select Qualified Silver 2700

Select Qualified Bronze 5250

Available through Federal Exchange

Preferred Plus Gold 1500

Preferred Plus Silver 3000

Preferred Plus Silver 3000 CSR1

Preferred Plus Silver 3000 CSR2

Preferred Plus Silver 3000 CSR3

Preferred Plus Bronze 6350

Preferred Plus Bronze 5250 HSA

Preferred Plus Silver 3000 HSA

Preferred Plus Silver 3000 HSA CSR1

Preferred Plus Silver 3000 NQHSA CSR2

Preferred Plus Silver 3000 NQHSA CSR3

Rate information

Area 1 (ZIP codes 995xx)

Rate map

Preferred Plus Gold 1500, Silver 3000, Bronze 6350

Preferred Plus Bronze 5250 HSA, Silver 3000 HSA

Area 2 (ZIP codes 996xx, 997xx)

Preferred Plus Gold 1500, Silver 3000, Bronze 6350

Preferred Plus Bronze 5250 HSA, Silver 3000 HSA

Area 3 (ZIP codes 998xx, 999xx)

Preferred Plus Gold 1500, Silver 3000, Bronze 6350

Preferred Plus Bronze 5250 HSA, Silver 3000 HSA

Provider network

Alaska Heritage Plus

Individual Pediatric Dental Plan

All of our individual and family plans include pediatric dental benefits. These benefits are available to individual members under age 19.

Preferred Adult Dental Plan

For family members 19 years of age and older we offer adult dental plans. Coverage is available to members who have medical coverage with us either on or off the Federal Exchange.

2017 Adult Dental Plan

2016 Preferred Adult Dental Plan flyer

Applying for coverage on the Preferred Adult Dental Plan is easy. Existing members who want to add this plan to their coverage use the Preferred Adult Dental Plan application. Consumers applying for new coverage use the Premera Individual Enrollment Application.

2016 Preferred Adult Dental Plan application

Services on the Preferred Adult Dental Plan are provided as outlined in the list of covered services.

Covered services list

Dental/Vision/Hearing Plan

Premera also offers a plan that combines dental, vision, and hearing coverage to all Alaska residents.

2017

Dental / Vision / Hearing brochure - coming soon!

Dental / Vision / Hearing application

2016

Dental / Vision / Hearing brochure

Dental / Vision / Hearing application

Premera Blue Cross Blue Shield of Alaska has selected Washington National Insurance Company, a company focused on supporting health plans with supplemental health and life insurance that complements your customers' total health insurance coverage from Premera.

Help your customers gain the additional financial protection with the following products from Washington National:

Accident

• Accident Assure®
• Supplemental protection against accidental injuries

View the Washington National Accident Assure® Brochure

Critical Care

• Washington National Critical Solutions®
• Critical illness coverage that's simple to understand and use

View the Washington National Critical Solutions® Brochure

Life

• Washington National Life Assure℠
• Straightforward, assured life insurance that keeps pace with your life

View the Washington National Life Assure Brochure℠

About Washington National

Since 1911, Washington National has helped Americans protect themselves and their families from the financial hardship that often comes with critical illness, accidents or loss of life. Washington National insures nearly 1 million policyholders and 25,000 employer groups offering important benefits at a competitive price. You can count on Washington National for dependable, high-quality service and support.

To learn more about Washington National and their products please visit: washingtonnational.com. Products are subject to state availability. Contact your Premera producer support representative for more details.

Washington National Insurance Company is an independent provider of supplemental health and life insurance that does not provide Blue Cross Blue Shield products or services. Washington National Insurance Company is solely responsible for its policies. Washington National Insurance Company policies are not considered “qualified health plans” and do not provide essential health coverage as required by the Affordable Care Act. Washington National's policies are considered “excepted benefits” policies which do not meet the individual mandate requirements of the Affordable Care Act.

Sales brochure

Sales Brochure

Plan summaries

Preferred Plus Gold 1500

Preferred Plus Silver 2000

Preferred Plus Silver 3000

Preferred Plus Bronze 6350

Preferred Plus Silver 3000 HSA

Preferred Plus Bronze 5250 HSA

Rate map

Rate Map

Rate sheet

Preferred Plus Gold 1500, Silver 2000, Silver 3000, Bronze 6350 - Area 1

Preferred Plus Gold 1500, Silver 2000, Silver 3000, Bronze 6350 - Area 2

Preferred Plus Gold 1500, Silver 2000, Silver 3000, Bronze 6350 - Area 3

Preferred Plus Silver 3000, Bronze 5250 HSA - Area 1

Preferred Plus Silver 3000, Bronze 5250 HSA - Area 2

Preferred Plus Silver 3000, Bronze 5250 HSA - Area 3

Brochure

AI/AN Brochure

Plan summaries

Blue Cross Blue Shield Plus 1500, a Multi-State Plan

Blue Cross Blue Shield Plus 2000, a Multi-State Plan

Blue Cross Blue Shield Plus 2000 CSR1, a Multi-State Plan

Blue Cross Blue Shield Plus 2000 CSR2, a Multi-State Plan

Blue Cross Blue Shield Plus 2000 CSR3, a Multi-State Plan

Blue Cross Blue Shield Plus 3000, a Multi-State Plan

Blue Cross Blue Shield Plus 3000 CSR1, a Multi-State Plan

Blue Cross Blue Shield Plus 3000 CSR2, a Multi-State Plan

Blue Cross Blue Shield Plus 3000 CSR3, a Multi-State Plan

Blue Cross Blue Shield Plus 6350, a Multi-State Plan

Blue Cross Blue Shield Plus 3000 HSA High, a Multi-State Plan

Blue Cross Blue Shield Plus 3000 HSA High CSR1, a Multi-State Plan

Blue Cross Blue Shield Plus 3000 HSA High CSR2, a Multi-State Plan

Blue Cross Blue Shield Plus 3000 HSA High CSR3, a Multi-State Plan

Blue Cross Blue Shield Plus 5250 HSA High, a Multi-State Plan

Rate map

Rate Map

Rate sheet

BCBS Plus Gold 1500, Silver 2000, Silver 3000, Bronze 6350, a Multi-State Plan - Area 1

BCBS Plus Gold 1500, Silver 2000, Silver 3000, Bronze 6350, a Multi-State Plan - Area 2

BCBS Plus Gold 1500, Silver 2000, Silver 3000, Bronze 6350, a Multi-State Plan - Area 3

BCBS Plus Silver 3000, Bronze 5250 HSA High, a Multi-State Plan - Area 1

BCBS Plus Silver 3000, Bronze 5250 HSA High, a Multi-State Plan - Area 2

BCBS Plus Silver 3000, Bronze 5250 HSA High, a Multi-State Plan - Area 3

Access - Coverage for the big stuff

Safeguard Safeguard III - The security of knowing you're covered for the basics

PeakPeak III - The broadest range of covered benefits

Active HSA Active HSA III Secure HSA - Coverage that helps you manage your healthcare expenses

2015 Grandfathered Plan Rate Sheet

2016 Grandfathered Plan Rate Sheet

2015 Non-Grandfathered Plan Rate Sheet (Safeguard suite)

2015 Non-Grandfathered Plan Rate Sheet (Alaska Best Care Suite) - For closed plans with original start dates from April 1, 2010 to April 15, 201

2015 Non-Grandfathered Plan Rate Sheet (Alaska Peak suite) - For closed plans with original start dates from May 1, 2010 until Dec. 15, 2010

2016 Non-Grandfathered Plan Rate Sheet

Individual Medical Exclusions

Summary of Benefits and Coverage

Individual and Family Plans

Individual and Family Enrollment Application - (For non-grandfathered plans with start dates on or after May 1, 2012)

Application for the Addition of Family Members to an Individual/Family or Group Conversion Plan

Existing Member Dental Application

AFT Authorization Form for Individual Major Medical

Tobacco Certification Form - For plans as of 1/1/14 enrollment dates

Non-Smoker Certification Form - For plans prior to 1/1/2014

Underwriting Plan Change Matrix - For plans with start dates on or after May 1, 2012.

Medical and Dental Claims

Claim Form

Pharmacy

This section provides Fax-back forms to submit a request for review and approval and forms related to Express Scripts Home Delivery or prescription drugs

Express Scripts Home Delivery Mail-Order Form - Order prescription drugs through the mail from Express Scripts. On behalf of Premera, Express Scripts is an independent company providing pharmacy benefits services.

Health, Allergy & Medication Questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.

Prescription Drug Reimbursement Form - Apply for reimbursement of your prescription costs.

Disclosure and Privacy

This section provides release of information forms

Authorization for Release of Healthcare Information and Records

Authorization for Release of Psychotherapy Notes

Disclosure Accounting Request

Non-Disclosure Request

Request for Amendment of Record

Request for Inspection of Records

Miscellaneous

Affidavit of Domestic Partnership

Individual Domestic Partner Eligibility Requirements

AFT Authorization Form for Individual Major Medical

HSA Authorization Form for UMB Bank

Producer of Record Change Form

Student Status Verification

Waiver of Coverage

Producer Supply Form

Summary of Benefits and Coverage

As a part of the Affordable Care Act of 2010, all health plans must provide a summary of benefits in a standard four-page format. These summaries help people understand how a plan works and makes comparing plans easier.

Contract Booklets

2015 contract booklets

Plan Mapping

2017 Rate Map

2017 Mapping Grid

2017 Mapping Grid – Grandmothered Plans

2016 Plan Mapping Matrix

Mobile App

Teach your clients about our mobile features with our mobile app flyer!

Apply for coverage directly through Premera:

Open enrollment ended on January 31. If your client or a family member has experienced a major life event (such as marriage, divorce, birth or adoption of a child), they may be eligible to enroll in a special enrollment period

If your clients qualify, please have them apply online or apply by mail by following these steps:

1. Complete the paper application

2. Provide proof of residence for the primary applicant, which means the following:

   • A valid Alaska driver's license, state-issued identification card, tribal or military identification that includes the applicant's photograph and residential address.

   • Plus any ONE of the following documents:

   • Current lease or rental agreement
   • A filed property deed or title for your current residence
   • Home utility bill (such as gas, electricity, water, garbage, landline telephone, or cable) or hook-up work order dated within the past 60 days.
   • Voter registration card

   • Plus any ONE of the following documents:

   • Latest credit card statement or bank statement
   • Professional license (nurse, doctor, engineer, etc.)
   • A professionally-filed tax return or filed copy sent to you by the IRS for the most recent tax filing year
   • IRS W-2 form for the most recent tax year
   • Current paystub from employer

   • A complete copy of each document must be submitted. All documents must show the applicant's full name and current residential address. A post office or mail delivery address is not acceptable.

3. Then mail the application and proof of residency to:
   Premera Blue Cross Blue Shield of Alaska
   PO Box 327, MS 295
   Seattle, WA 98111-0327

Applying for coverage through the Federal Exchange

If your clients qualify for health plan bill credit assistance, cost share reduction plans or American Indian/Alaska Native plans, they will want to enroll in a plan through the federally facilitated marketplace (FFM) at Healthcare.gov.

Clients who do not qualify for assistance can also apply through the FFM at Healthcare.gov

For more information about an online tool that will let you enroll your FFM clients in just a matter of minutes, please contact Producer Support at producer.support@premera.com or 877-205-9725.

Is your client eligible to apply?

Individuals eligible to apply for a Premera plan if they are:

• A resident of and have a principal residence in the state of Alaska
• Not entitled to Medicare A or B (including entitlement due to disability), or a Medicare Choice or Medicare Advantage plan.
• Applying during an open enrollment period or when they have a qualifying event

Eligible dependents that can enroll on a plan include:

• Spouse or domestic partner
• Natural or legally adopted child(ren) under the age of 26
• Children under age 26 when you or your spouse are the legal guardian
• A legally placed ward of the subscriber or spouse (including foster children)