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Policies & Practices

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We know healthcare is complicated. You can find more information by topic to use your plan.

To learn more about your plan benefits and services, sign in and refer to your plan benefits and benefit booklet. You can also refer to your Summary of Benefits and Coverage, or contact us.

Medical

Premera's medical plans do not cover all health care expenses and include limitations and exclusions. Sign in and check your benefit booklet to determine which services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan may contain exceptions to this list based on state mandates, essential health benefits, or the plan design purchased.

  • All medical and hospital services not specifically covered in, or that are limited or excluded by your benefit plan, including costs of services before coverage begins and after coverage ends
  • Cosmetic surgery, except as specifically described in your member benefit booklet
  • Custodial care
  • Experimental and investigational procedures, services, and drugs, implantable drugs (non-contraceptive related), and certain injectable drugs, including injectable infertility drugs
  • Infertility services including donor egg retrieval, artificial insemination, and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI, and other related services, unless specifically listed as covered in your plan documents
  • Nonmedically necessary services or supplies
  • Radial keratotomy or related procedures
  • Reversal of sterilization
  • Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies, or counseling
  • Special or private duty nursing

To learn more about the costs you may have to pay, sign in and view your plan benefits and your benefit booklet, or contact us.

Or, view the summary of benefits and coverage.

Premera Blue Cross and its affiliate Premera Blue Cross HMO want to make sure you’re getting the care you need. Annual check-ups can identify problems early, before they become more serious.Regular visits with your doctor also allow you to discuss any health concerns you may have, including more complex health conditions.

Premera HMO members can select a primary care provider (PCP) in the HMO network that best fits their needs and the needs of their family. Members can select any in-network PCP they choose.

Explore providers in the HMO network.

You may seek specialty care and behavioral healthcare from in-network or out-of-network providers. Be sure to talk with your PCP about your preferences. Depending on your plan, you or your family members may need a referral from your PCP in order to accessspecialty care. Refer to your member benefit booklet for details.

Participating in-network providers and facilities are listed in Find a Doctor. Sign in to see providers in your network. Certain nonemergency hospital and other medical services require preapproval from Premera. Contact us if you have difficulties finding a provider or have other questions.

For eligible members, Premera provides a free service, My Advocate, to help schedule doctor visits. If you don’t have a PCP, My Advocate can help you find one in your network. My Advocate is managed by an independent company, Change Healthcare, on behalf of Premera.

Members may seek specialty care and behavioral healthcare from in-network or out-of-network providers. Be sure to talk with your PCP about your preferences. Depending on your plan, you may need a referral from your PCP to access specialty care. Members who have the Premera HMO plan can only get referrals for specialty care from their PCP.

Refer to your member benefit booklet for details.

Participating in-network providers and facilities are listed in Find a Doctor. Sign in or create an account and use Find a Doctor to find providers contracted with your specific plan. Certain nonemergency hospital services require preapproval from Premera. Customer service can assist you with the directory or help you locate a provider or facility within a specific geographic area.

You have options if you need after office hours or emergency care. Sometimes it's hard to know what to choose, but there's a big difference in time and money.

24-Hour NurseLine

Call our free, confidential 24-Hour NurseLine to speak with a nurse, who will ask the right questions, listen to your concerns, and help you determine where and when to seek treatment. The NurseLine number is listed on the back of your member ID card.

Note: if there isn't a NurseLine number on your card, your plan might not offer this service.

Nonlife threatening

Urgent care facilities provide quick, convenient care for health needs that aren’t life threatening but can’t wait until the next day or longer. They are open outside of regular business hours and are less expensive than emergency room care. To locate the nearest urgent care facility, use Find a Doctor.

Conditions that can be dealt with in an urgent care facility include:

  • Ear infections
  • Low fever or mild flu symptoms
  • Minor rashes, cuts, bites and sprain

Life threatening

Call 911 or go to the emergency room if you are in severe pain or your condition is endangering your life. To locate the nearest ER, search using Find a Doctor.

Examples of medical emergencies include:

  • Suspected heart attacks
  • Strokes
  • Broken bones

When you are covered by Premera through an employer-sponsored plan, your plan offers specific levels of healthcare benefits wherever you live or travel. Coverage when traveling varies by plan. Some plans only cover emergency care outside of the service area, while others extend full care anywhere in the United States. When you are covered by Premera as an individual, coverage applies in your local area but not when traveling out of your area.

To understand how to use your plan, refer to your benefit booklet.

Participating in-network providers and facilities are listed in Find a Doctor. Sign in or create an account and use Find a Doctor to find providers contracted with your specific plan. Certain nonemergency hospital services require preapproval from Premera. Customer service can assist you with the directory or help you locate a provider or facility within a specific geographic area.

Premera members have access to a comprehensive, nationwide network of retail pharmacies. They also have access to a convenient mail order pharmacy, Express Scripts Home Delivery. To find information about your drug benefits, use the following links.

Find a network pharmacy near you:

View procedures that affect your drug coverage:

View your drug list and see which drugs have limitations on how they are prescribed or purchased:

  • Search drug lists
  • Sign in and go to Prescriptions to connect to Express Scripts and view your personalized pharmacy benefits

Find out how to obtain restricted drugs:

Health plan information

The goal of the Utilization Management Program is to promote the delivery of appropriate, effective, and efficient medical care to our members. This includes medical services, medical equipment, and pharmacy. If you have questions about the Utilization Management program, contact us. TTY and language assistance are available for callers with questions about utilization management. Our TTY number for deaf or limited-hearing members is 711.

Premera and its delegates do not reward or pay our staff based on how members use healthcare services. We do not base their pay in any way on how or if they decide to approve or deny coverage. We do not reward or pay our staff to make decisions that cause members to use fewer healthcare services.

We do review some healthcare services before members get them. These reviews help us decide if and how to cover those services. When we do a review, we look only at whether services meet medical criteria for your condition and whether your plan covers them.

“We” includes Premera and any of its delegates—any people or organizations we hire to review requests.

Premera is committed to assuring quality care for its members. Our Quality Program makes sure that the healthcare our members receive is evaluated, measured, improved, and communicated about. The Premera Quality program is designed to improve members’ health and the quality and safety of care and service. The Quality Improvement Committee conducts a formal, system-wide quality assessment annually, which includes an annual program evaluation of the quality of its health services. Learn more  (PDF document)

Teams of doctors, pharmacists, and nurses review new drugs and medical services. The Medical Policy Committee reviews new technology and other medical or surgery services. The Pharmacy and Therapeutics Committee reviews new drugs and some therapies. These committees decide if a new drug or service will be covered. Their decisions are based on sound published scientific studies. Their decisions help protect against the use of treatments that are not proven or not safe.

The links below are to websites on general health and safety information on health care services. The information stated on these sites has not been evaluated by Premera, and is provided only as general information. For complete information on the services covered by your health plan, please refer to your benefit booklet, and premera.com.

Safety information

It's important to think about safety when you need health care. Communication with your doctor is perhaps the most important link to better care and health outcomes. These links provide useful tools to help you communicate with your doctor about care and medications.

Medication list

For a medication list and a variety of tips and tools related to medications, go to: http://www.safemedication.com.

10 questions to ask

Asking questions is important to safe care. The Agency for Healthcare Research and Quality provides useful resources including The 10 Questions You Should Know.

Ask Me 3®

Ask Me 3® is an educational program that encourages patients and families to ask three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy.

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?

Learn more by visiting Institute for Healthcare Improvement.

Making healthcare safer

A patient safety report that addresses safety practices is available from the Agency for Healthcare Research and Quality.

To request certain records containing your personal information, complete:

Use the Information Release form to give someone permission to obtain and discuss your personal and health information. This includes sensitive information about substance use disorder, reproductive health, and mental health. To share your personal records, complete:

You can also authorize members on your plan to see your sensitive information on premera.com or ConnectYourCare (personal funding account).

Personal Health Support

Premera offers a personalized, one-on-one support program to help you manage chronic conditions such as asthma, coronary artery disease, heart failure, chronic obstructive pulmonary disease, diabetes, or depression. Personal Health Support assists members in making healthy lifestyle changes and helps develop self-management strategies for better health. This program is available at no extra cost to you.

Tools and resources

Participants have access to a personal health support team of registered nurses, registered dietitians, and licensed mental health professionals with expertise in chronic condition management. The program also includes:

  • One on one support from a clinician to identify and address barriers to improved health.
  • Educational materials, health monitoring tools, and community resources to address healthcare barriers.
  • Help for understanding tests and prescription medications.

Participation in this program is voluntary, and you can withdraw at any time.

Ways to join

  • Premera identifies you as someone who can benefit from the program, based on your previous claims and then reaches out to you directly.
  • Your doctor or another healthcare provider refers you to the program and Premera contacts you.
  • For Premera Blue Cross members with employer-sponsored plans, call Premera at 800-722-1471 (TTY: 711) or PersonalHealthSupport@premera.com.
  • For members with individual plans (if you bought your plan directly from Premera or WAhealthplanfinder.org): call 800-607-0546 (TTY: 711).
  • For Premera Blue Cross HMO members, call 844-722-4661 (TTY: 711) or PersonalHealthSupport@premera.com.

Note: For benefit and claims questions, contact the customer service number on the back of your member ID card. Or, sign in and send an email from your Secure Inbox.

More information

The Premera Personal Health Support services offer support to help you or a family member with serious health problems.

Our Personal Health Support clinicians include registered nurses, registered dietitians, licensed mental health professionals, and intake coordinators/care advisors. They will help you with any concerns you have with your health or healthcare. This is voluntary and free as part of your health plan.

How to make a referral

You may refer yourself or an eligible family member.

NOTE: For benefit and claims questions, either contact the customer service number on the back of your member ID card or sign in and send an email from your Secure Inbox.

At Premera the goal is to ensure equitable access to quality, affordable healthcare tailored to the specific needs of different communities. See how we are supporting Healthy Communities.

Make sure you're covered

Don't be surprised by a bill you were not expecting

Did you know that you may be required to get an approval for coverage from your health plan before you have a planned medical service or procedure? This is called a preapproval, and it helps you:

  • Find out if you're covered by your benefits before you have your scheduled procedure
  • Save money and avoid extra cost
  • Get an estimate of your out-of-pocket for copay and deductible costs before you get your service
  • Avoid unnecessary services

Learn more about preapprovals.

View the list of services and drug treatments requiring prior authorization.

Services that do not require preapproval

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

Pharmacy preapproval program

If you have a prescription plan benefit, some drugs must be approved for coverage through our pharmacy preapproval program.

Learn more about drugs requiring preapproval

Your rights and resources

These are your rights as a health plan member:

  • You can easily get information about the organization, its services, and its healthcare practitioners and providers.
  • You can easily get information about your member rights and responsibilities.
  • We will treat you with respect. We will recognize your dignity and right to privacy.
  • You can work with your healthcare provider to decide on treatments you need.
  • You can talk honestly about the treatments that are right for your conditions, regardless of cost or benefit coverage.
  • You can make complaints or appeals about us or the care or service we provide.
  • You can recommend changes to our member rights and responsibilities policy.
  • You can choose your healthcare providers.
  • We will keep things you tell us about your health plan claims and other related information private.
  • Your healthcare and healthcare coverage information will stay protected.
  • You can review and get copies of your personal information on file.
  • You can get screening and stabilization emergency services when and where you need them. You do not need prior authorization, regardless of cost or benefits coverage. This applies if severe pain, injury, or sudden illness convinces you that your health is at great risk.
  • You can continue to get care from your specialty provider for up to 90 days or until you complete your care. This applies if you are getting treatment for a chronic or disabling condition. It applies if you are in your second or third trimester of pregnancy. It applies when you involuntarily change your healthcare plan. It applies if your provider leaves the network for any reason other than cause.

These are your responsibilities as a health plan member:

  • Give as much of the information as you can that Premera and its providers need in order to provide care.
  • Follow plans and instructions for care that you have agreed to with your providers.
  • Try to understand your health problems.
  • Work as much as possible with your healthcare providers to develop treatment goals you can agree on.
  • Try to keep healthy habits, such as exercising, not smoking, and eating a healthy diet.
  • Disclose relevant information. You must try to communicate clearly what you want and need.
  • Avoid knowingly spreading disease.
  • Understand your healthcare provider's obligation to provide care equally and efficiently to other patients and the community.
  • Learn about your health plan coverage and options, including all covered benefits, limitations and exclusions, and rules about the use of information.
  • Understand how to appeal coverage decisions.
  • Show respect for other patients, health workers, and health plan employees.
  • Make a good-faith effort to meet financial obligations.
  • Follow the administrative and operational procedures of your health plan and healthcare providers.
  • Report wrongdoing and fraud.

At Premera, we are committed to maintaining the confidentiality of your medical and financial information. The Notice of Privacy Practices informs you about how we may collect, use and disclose your personal information and your rights regarding that information.

Notice of Privacy Practices

Aviso de Practicas de Privacidad

To get language assistance, contact Customer Service.

Our TDD/TTY number for deaf, hard of hearing, or speech-impaired members is 711.

When you receive care from providers in the network, they will process your claims (requests for payment) directly with us. This means you don't need to manage any paperwork. However, if you receive care from a non-network provider, you might have to pay the doctor, dentist or other provider for the service and then file a claim with us for reimbursement.

To file a claim for reimbursement:

  1. Complete and sign the form for your type of plan.
  2. Staple an itemized bill from the provider to the form.
  3. Mail your claim to the address shown on the form. See your benefit booklet for your health plan for more details on filing claims.

See your benefit booklet for more details on filing claims.

Request a claim review

If you disagree with how a claim was paid—as described on your explanation of benefits (EOB)—you can request a review. We must receive your request to review a claim within 180 days after you receive your EOB. You can either contact us or submit a written request. If you suspect that payments were made for services you didn't receive, please call the Fraud Hotline at 800-848-0244.

Submit a written request

If you prefer, you can submit a written request so you can make a copy for your records. Along with your written request, include a copy of your explanation of benefits (EOB) to identify details of the disputed claim. You may also include any other documents or information that may help resolve your claim to your satisfaction. After we receive your request, we'll send you detailed information about our appeals process, including the timeframes for each step of the process. Send your request to:

For members with both employer-sponsored plans AND Premera HMO plans

  • Premera Blue Cross
    Attn: Claims
    PO Box 91059
    Seattle, WA 98111–9159

For members with individual plans (if you bought your plan directly from Premera or WAhealthplanfinder.org)

  • Premera Blue Cross
    PO Box 21702
    Eagan, MN 55121

Questions or concerns?

Contact us

Note

Some groups may have a separate contact phone number. Confirm your contact number on the back of your member ID card before calling. For more detailed information about your benefits, see your contract or contact us.

To submit a complaint, choose the appropriate member form:

Subjects can include the following:

  • The care or service we provide
  • The quality or availability of a healthcare service
  • The care or service you get from any providers in our network

You also have the right to appeal any action we take or decision we make about your coverage or services.

Always carry your Premera member ID card and show it to doctors, other providers, and pharmacists whenever you need care or prescriptions. Find out what each item on your ID card means.

Each time Premera processes a claim submitted by you or your healthcare provider, we describe how we processed it in the form of an explanation of benefits (EOB). The EOB is not a bill. It simply explains how your benefits were applied to that claim. It includes the date you received the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. It also tells you how much has been credited toward any required deductible. Each time you receive an EOB, review it closely and compare it to the receipt or statement from the provider.