Premera Blue Cross Response to COVID-19

The FDA Vaccine Advisory Committee voted to approve the Emergency Use Authorization (EUA) for the Moderna COVID-19 vaccine for those 18 and older. The CDC’s Advisory Committee on Immunization Practices (ACIP) recommended use of the Moderna vaccine. The Scientific Safety Review Workgroup, made up of members from Washington, Oregon, Nevada, Colorado, and California, met and voted to recommend the vaccine for immediate use.

Earlier in December the Pfizer COVID-19 vaccine for those 16 and older was given an Emergency Use Authorization (EUA).

Two vaccines have made it through all the required trials and have received EUA from the FDA. Vaccine made by AstraZeneca is expected in the first quarter of 2021. Johnson and Johnson (J&J) submitted an Emergency Use Authorization (EUA) application for their COVID-19 vaccine on February 4. FDA Vaccine Advisory Committee (VAC) is scheduled for February 26 to discuss the J&J COVID-19 vaccine EUA. J&J intends to provide the purchased 100 million doses in the first half of 2021, however, initial supplies are expected to be extremely limited.

The vaccine development and testing followed all protocols for standard drug testing as required by the FDA. Clinical trials provide data and information about how well a vaccine prevents an infectious disease and about how safe it is. The FDA evaluates these data, as well as manufacturing information, to assess the safety and effectiveness of vaccines. FDA then decides whether to approve a vaccine or, in the event of a public health emergency, authorize it for emergency use in the United States. The vaccines that are applying for approval have made it through all the FDA-required safety checks and testing requirements.

In addition, the Scientific Safety Review Workgroup, made up of members from Washington, Oregon, Nevada, Colorado and California, will review the EUA authorizations and determine if they will recommend the vaccine for immediate use.

An EUA is an Emergency Use Authorization. This is a type of temporary approval that may be used by the FDA in a public health emergency to ensure access to critical vaccines & treatments related to the emergency. The vaccines still do thorough and rigorous testing and review before being distributed, but the process is shortened. We’ve seen several new drugs given EUA approval for use in treating COVID-19 symptoms in 2020. All vaccines and drugs will continue to be reviewed and monitored and are expected to receive FDA approval after the full review.

CDC will further assess the effectiveness of COVID-19 vaccines after they are approved or authorized for emergency use by FDA and recommended for public use. These real-world assessments will compare groups of people who do and don’t get vaccinated and people who do and don’t get COVID-19 to assess how well COVID-19 vaccines are working to protect people.

Right now, we don’t know if any one vaccine is better than another. Initial data released by the manufacturers have shown very promising results of the vaccines being effective (>90% effective in trials at avoidance of symptomatic infection).

We do know that the Moderna, Pfizer, and AstraZeneca vaccines are two-dose vaccines, meaning you’ll need to have two shots a certain length of time apart. One vaccine has been shown to be particularly effective in older adults.

The CDC Director has approved additional phases of the COVID-19 vaccination program. Note that each state can vary who is included in each phase or accept the CDC recommendations.

Phase 1a: Healthcare personnel and residents/staff of long-term care facilities

1. Healthcare personnel. Healthcare personnel are defined as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials.
2. Residents and staff of long-term care facilities. Long-term care facility residents are defined as adults who reside in facilities that provide a variety of services, including medical and personal care, to persons who are unable to live independently.

Phase 1b: Frontline essential workers and Persons aged 75 years or older

Phase 1c: Persons age 65-74 years, persons aged 15-64 with high-risk conditions, essential workers not recommended in Phase 1b

The National Academies of Sciences, Engineering, and Medicine (NASEM) and the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) will provide additional guidance on the next vaccination phase in early 2021.

Each state can determine if they’ll follow the CDC guidance for each phase. States have their own Department of Health websites that will be tracking information, providing updates on available vaccine doses, who is eligible to administer the vaccine, and who is included in each phase. Visit the CDC website for specific state information – scroll to “How do I get a vaccine?” and select your state.

Phase 1b Tiers (in order) Groups

Tier 1

• All people 65 years and older
• People 50 years and older in multigenerational households. These individuals would be at risk either due to:
• Vulnerability (e.g., older adult or elder who cannot live independently and is being cared for by a relative or in-home caregiver)
• Risk of exposure (e.g., older adult or elder who is living with someone who works outside the home, older adult or elder taking care of a grandchild)
• Not include an older adult who is able to live independently and is taking care of the individual’s children
• Note: Washington state is currently in Tier 1.

Tier 2

• High-risk critical workers 50 years and older who work in certain congregate settings

Tier 3

• People 16 years and older with 2 or more co-morbidities or underlying conditions

Tier 4

• High risk critical workers under age 50 in certain congregate settings (as noted in Tier 2)
• People (residents, staff, volunteers) in congregate living settings (e.g., correction facilities, prisons, jails, detention centers; group homes for people with disabilities) and people experiencing homelessness that access services or live in congregate settings (e.g., shelters, temporary housing)

View more WA state guidance.

View image of additional phases and tiers.

Most states are now requiring proof of residency for any COVID vaccination. That may include a driver’s license or utility bill showing your current address.

Washington received its first allotment of the Pfizer vaccine on December 14 and began administration of the vaccine to high-risk workers in health care settings, high-risk first responders, and patients and staff of long-term care facilities. It’s estimated around 500,000 people in Washington will be eligible for the vaccine in phase 1a. The Moderna vaccine shipment is currently expected in the next week and vaccinations will begin shortly after distribution.

CVS Pharmacy, which is preparing to begin vaccinations in long-term care facilities, said that December 21 would be the earliest vaccine administration can start in the facilities.

The Pfizer COVID-19 vaccine is a two-dose vaccine given 21 days apart. The Moderna vaccine is also a two-dose vaccine given 30 days apart. The CDC will be issuing a guidance that addresses use in those with vaccine allergic reactions, are pregnant/breastfeeding, and have weak immune systems.

Information about vaccines and distribution will continue to evolve.

We anticipate that broad scale vaccination across our populations (those not in the first few phases) will likely not be until mid-2021.

Information about vaccines and distribution will continue to evolve.

For general questions about COVID-19 Vaccines and Vaccine Trials, and for the CDC playbook:
Centers for Medicare and Medicaid Services (CMS)
Centers for Disease Control and Prevention (CDC)

The cost of the actual vaccine is currently being covered by the government. The cost of administering the vaccine will be covered by insurers, like Premera. We expect the vaccines will be billed by dose, similar to how other 2-dose vaccines are billed.

We believe most hospital facilities and pharmacies will receive distribution of the vaccine and will be able to give the vaccines. Check with your healthcare provider or your pharmacy to see if they are administering the COVID-19 vaccine when it becomes available to you. The CDC website has information on each state. Go to "How do I get a vaccine?" and select your state. In Washington state, you can use the Phase Finder tool.

For Medicare members, providers must qualify and enroll as a mass immunizer (or other Medicare provider type that allows billing for administering vaccines), so they can bill for administering COVID-19 shots.

For the general population, to receive/administer COVID-19 vaccine, vaccination provider facilities/organizations must enroll in the federal COVID-19 Vaccination Program coordinated through their state’s immunization program. Enrolled COVID-19 vaccination providers must be credentialed/licensed in the state where vaccination takes place, and sign and agree to the conditions in the CDC COVID-19 Vaccination Program Provider Agreement.

Contact your healthcare provider to see if they are qualified to administer the COVID-19 vaccine or use Washington state's Phase Finder tool.

Check with your state to determine what identification or referral may be required for each phase. In Washington state, use the Phase Finder tool.

Not currently for those under 16. The vaccines were only tested on adults. The Pfizer vaccine is approved for those 16 and older; Moderna is approved for those 18 and older. We’ll need additional studies to determine if these vaccines will be effective for those under age 18.

You may not be fully protected from contracting the COVID-19 virus. There are many vaccines that require more than one dose to ensure adequate immune response (i.e., antibodies) and to protect you from contracting a virus.

For some vaccines (primarily inactivated vaccines), the first dose does not provide as much immunity as possible. So, more than one dose is needed to build more complete immunity. The vaccine that protects against the bacteria Hib, which causes meningitis, and the vaccine that protects against shingles, are good examples.

If you get your second shot too early or too late, you DO NOT need to repeat the dose.

If you accidentally get the wrong vaccine for your second shot, you DO NOT need to repeat the dose. For example, if you get the Pfizer vaccine and then for your second shot you accidentally get the Moderna vaccine, you do not need another dose of either the Pfizer OR Moderna vaccine.

You should receive a vaccine card from the provider letting you know when you’ll need to get your second dose and which vaccine you received. You may also be asked to provider your email address or phone number for a reminder as well. Premera is looking into reminders as well, but because claims for vaccinations can come in up to 60 days after the fact, we may not be able to provide timely reminders.

There are no requirements currently that you must get the vaccine. It is, however, highly recommended.

We can't provide you with employment law advice on this topic. You’ll want to check in with your own legal counsel to determine if there are any restrictions or considerations to that requirement. The vaccine will be covered under your health plan benefits.

There are a few groups that will be offering clinics soon. Employers will be able to schedule and provide vaccines for employees that fall into one of the phases; they won't be able to provide vaccines for all employees until we reach the state where everyone is able to be vaccinated. Currently, because of the limited amount of available vaccine, each state is managing the distribution primarily to providers and pharmacies. Contact your account manager if you're interested in scheduling an onsite vaccination clinic.

Not quite yet. According to studies, we need more than 65% of the population to get the COVID-19 vaccine to begin to see protection among the general population. Once you receive both doses of a vaccine, you may be able to resume normal activities. In the meantime, continue to exercise caution, wash your hands frequently, and wear a mask.

Just like with the flu vaccine, if you were exposed or in the early stages of the disease, the vaccine won’t be effective. It generally takes two weeks for a vaccine to become effective in the body (after the second dose in the case of the COVID-19 vaccine). That’s why some people feel like they get the flu when they get a flu vaccine. Their immune system may be ramping up or they may have been exposed and start feeling the symptoms before the vaccine can become effective.

Also, like with other vaccines, they aren’t 100% effective. It’s still possible to get sick with COVID-19 even after getting the vaccine. However, the chances are of acquiring it are greatly reduced, and if you get sick typically the course of the disease is shorter and less severe.

No changes are needed to your health plan to ensure coverage once the vaccine is available for administration.

Every business has a different set of circumstances and requirements that should guide their return-to-work decisions. At Premera, we, too, are evaluating the needs of our business and the needs of our employees as we determine when and how we’ll return to work.

Here are several resources that other businesses are finding helpful in determining their return-to-work strategy. We’ll continue to update this list as we come across additional resources.

1. Interim Guidance from the Centers for Disease Control and Prevention (CDC)

2. Workplace Decision Tree from the CDC

3. Wilson Perumal & Co Re-start Playbook

4. Seattle venture community, the Seattle Metropolitan Chamber of Commerce and the Bellevue Chamber of Commerce Playbook: Reopening the Workplace

5. Boston Consulting Group: COVID-19 New Normal Planning

6. State of Washington Safe Start WA

The CDC said in its Interim Guidelines that antibody test results “should not be used to make decisions about returning persons to the workplace or school.” The EEOC has stated that because of this, “requiring antibody testing before allowing employees to re-enter the workplace is not allowed under the ADA.” Current versions can’t reliably tell a person that they’re immune, can’t be re-infected or can’t transmit the virus to someone else. Because an immune response takes a while to show up, antibody tests will be negative for those newly infected with COVID-19. The Centers for Disease Control and Prevention (CDC) suggest that serologic testing should NOT be used to determine immune status in individuals until the presence, durability, and duration of immunity is established. This includes return to work scenarios.

We recognize this isn’t an easy situation, and we are in uncharted waters. We will continue to follow the science and do our best to advise and support you whenever possible. Premera recognizes how important it is for business to get up and running again. The economic pressure on our customers and our communities is unprecedented. We also believe returning to work as safely as possible, given the circumstances, is even more important.

We encourage employers to monitor local, state, federal guidance, and clinical expert organizations such as the CDC, as it pertains to return to work protocols. As new information is available, we’ll share that guidance with you. Premera will continue to be as flexible as possible to provide services to our members and supporting you with the most current and reliable information available.

Premera isn’t endorsing or sponsoring any of these resources. We thought you might find them useful as you begin planning your own return-to-work strategy.

Premera is extending the 30-day premium grace period to 60 days for fully insured groups. This grace period is in place to ensure your employees are receiving the care and medications they need during this critical time. Grace period information can be found in your group contract.

We’ve also implemented a grace period for OptiFlex monthly funding rates, and ASC Admin Fee only.

This is a “premium grace period” and not “claims grace period.” This guards against cancellation. Premera will hold medical, dental and vision claims during the unpaid premium period though members will continue to show as eligible in the system. This will also allow members to get their prescriptions filled.

During the first 30 days of the grace period, claims will be paid. Claims will then be held beginning day 31 to end of grace period. This applies to claims beginning March 1. During the unpaid premium period, your members will show as eligible in the system. This will also allow members to get their prescriptions filled.

The extension of the grace period doesn’t eliminate the obligation to pay the premium, but limits policy cancellation for late payment. Grace period information can be found in your group contract.

To assist with premium payments, we have added a temporary online payment with credit card option for groups. Credit card payments can only be made via the employer portal. We don’t have the ability to accept credit card payments over the phone. Optiflex groups are excluded from the new credit card payment option as Vimly does not accept credit cards.

For plans with LifeWise Assurance Company (LWAC) Stop loss, LWAC will extend the premium grace period to 60 days from the current filed 31 days in the contract. Delinquency notifications are delivered 30 days prior, stating the bill must be paid in full at the next cycle.

There are restrictions that generally do not allow carriers to offer premium discounts or waivers to employers.

Yes, in addition to the previous ACH payment option, we have added a temporary online payment with credit card option for groups. Credit card payments can only be made via the employer portal. We do not have the ability to accept credit card payments over the phone.

Premera will cover the 2.5% credit card transaction fee.

Self-funded groups can pay administrative fees through the new credit card payment option, but not claims reimbursements or stop loss premiums.

Optiflex groups are excluded from the new credit card payment option as Vimly does not accept credit cards.

The group will need to log into the secure Employer Portal and select billing, then select Pay Online and agree to the online payment Terms and Conditions, add your email address and setup their payment account information. For groups that already have an account set-up, you can manage your funding sources and change to a credit card.

Our current leave of absence (LOA) allowance for large and small group standard contracts is up to 90 days for furloughed employees and those on leave. For self-insured and OptiFlex groups, we'll allow them to waive the LOA and actively at work requirements. This extension is a Premera initiative.

No. Premera has made the business decision not to allow a special enrollment period without a standard qualifying event. Marriage, birth, loss of other coverage and other qualifying events can be found in the plan’s benefit booklets.

As part of its response to the coronavirus pandemic, the IRS announced in Notice 2020-29 that it is permitting increased flexibility for mid-year elections during calendar year 2020 for employer-sponsored health coverage, health flexible spending arrangements (FSAs), and dependent care assistance programs (DCAP). While the IRS Notice 20-29 allows additional flexibility, it does not require the health plan to adopt it. Some employees who waived enrollment may be eligible for individual plans on the State or Federal Exchanges. Contact your account manager for information.

On April 28, 2020, the U.S. Department of Labor's (DOL) Employee Benefits Security

Administration (EBSA) and the Internal Revenue Service (IRS) issued a rule and guidance, the EBSA Disaster Relief Notice 2020-01, which extends certain health care benefit deadlines.

The new rule and guidance extend certain health care benefit deadlines under the Employee Retirement Income Security Act (ERISA) and may impact your ConnectYourCare (CYC) programs, including Health Care Flexible Spending Accounts (FSAs), Health Reimbursement Arrangements (HRA), and COBRA.

Note: Plans not subject to ERISA are not required to comply with this rule, but the government encourages them to do so. Group Plans not subject to ERISA (e.g., church or government plans) and specific types of plans not subject to ERISA (e.g., Dependent Care Assistance Programs (DCAP) and Health Savings Accounts (HSA) or Commuter benefits) are some examples. You should consult your legal and benefits advisors to determine what impact this rule and guidance has on your plans.

If your plan isn’t subject to ERISA and you wish to opt-out of updating your plan design, contact your Premera account manager.

On Sunday, December 27, 2020, President Trump signed into law the Consolidated Appropriations Act 2021, a massive bill to fund the government that includes several provisions related to COVID relief.

This act provides temporary provisions for health care and dependent care Flexible Spending Account (FSA) plans, which may impact employers and their benefits plans. Under these provisions, employers are allowed, but not required to amend their Cafeteria Plans, and will be given ample time to do so. Amendments must be made by the last day of the calendar year following the plan year in which the amendment is effective. For example, calendar year 2020 plan amendments must be adopted on or before December 31, 2021.

Both Healthcare and Dependent Care FSAs have extension opportunities. To learn more about these provisions, and what you may be able to do, visit the Connect your Care site.

Contact your account manager if you're interested in taking advantage of any of these new flexible options.

Premera processes eligibility based on information provided by the employer. As long as the employee remains on the eligibility file, they will remain covered.

Premera processes eligibility based on information provided by the employer. As long as the employee remains on the eligibility file, they will remain covered.

We're waiving any re-rating rules for all groups (insured, OptiFlex, and self-funded). Groups who fall under an eligibility threshold will be able to maintain their rates through the end of their plan year.

Our standard rules remain which allow for reinstatement during the same plan year without experiencing a waiting period or losing their out-of-pocket accumulators. For groups whose plan year ends before June 30, we will treat them as if they were coming back within the same plan year.

Premera doesn’t have decision making authority on the state-regulated continuation of coverage rules. Anytime someone experiences a job loss, they may be eligible for individual plans on the state or federal exchanges.

Groups should be aware that individual coverage is available in Washington and you would meet the Washington Health Insurance Market place special enrollment criteria if they don’t meet eligibility requirements on their group plan. Due to the number of COVID-19 cases in our state, Washington Healthplanfinder extended a special enrollment period through May 8, 2020 for people without insurance. Coverage will start May 1, 2020 for people who enroll after April 8.

On April 29, the U.S. Department of Labor (DOL) announced guidance which extends a number of regulatory deadlines for ERISA plans and plan participants.

The DOL’s FAQ on health benefit and retirement benefit issues related to COVID-19 are intended to help employee benefit plan participants and beneficiaries, plan sponsors and employers impacted by the coronavirus outbreak understand their rights and responsibilities under ERISA. Model Notice FAQ.

Premera processes eligibility based on information provided by the employer. As long as the employee remains on the eligibility file, they will remain covered.

To support this increasing request, on April 28th, we launched new secure employer website functionality that will show the last 24 months of invoices. Employers will be able to access this on the billing page. This functionality will be permanent.

Premera expanded its telehealth network to give members greater access and address the increased demand related to COVID-19. This benefit is a Premera initiative and covers Insured and OptiFlex groups and self-funded groups that have opted in. This is a Premera initiative; see the COVID-19 Key Dates section in this FAQ for current dates.

Who’s eligible for this benefit?

This benefit will apply to members of insured groups, individual, grandfathered, non-grandfathered, associations and OptiFlex. Self-funded plans have the option to participate.

Who's not eligible: Shared admin, FEP, BlueCard, Providence, HCA, Medicare Supplement, Medicare Advantage, and self-funded plans that opt out.

Are brick and mortar in-network offices covered?

Yes. All in-network providers who offer telehealth options are covered under this expansion.

When should I use telehealth services and what can they help me with?

If you’re feeling ill with non-COVID-19 symptoms, you can contact a telehealth provider. Telehealth providers can answer questions, diagnose, and treat acute and chronic illness for non-COVID-19 related symptoms. They can also fulfill necessary prescriptions or order lab tests at local facilities.

In addition to our existing Premera contracted behavioral health providers (Talkspace, brick and mortar providers, and employer assistance programs), virtual access for behavioral health and substance use disorder treatment (opioid and alcohol) may include (depending on benefit plan design):

• Doctor On Demand – Doctor on Demand was added to our telehealth network. These services are available to member adults and children in all states.
• Boulder Care - Boulder Care is a digital care provider, offering long-term support and medication-based treatment for opioid use disorder (OUD) and common co-occurring conditions for members 18 years and older. Their digital platform allows patients to connect with providers 24/7 through secure video and messaging with clinicians, care advocates, and peer coaches. Boulder Care is working towards 50 states licensure. If they aren’t licensed in a certain state, they will transition the member to an in-network provider for the appropriate services.
• Workit Health – Workit Health is a digital care provider offering support for alcohol use disorder (AUD). Via Workit web and phone apps, members age 18 and older have a “recovery in their pocket” harm reduction and sobriety solution that provides 24/7 access to interactive therapeutic courses, online support groups supervised by licensed care teams. Workit is working towards 50 states licensure. If they aren’t licensed in a certain state, they will transition the member to an in-network provider for the appropriate services.

Additional covered telehealth services include:

• Applied behavioral analysis (ABA)
• Partial hospitalization programs (PHP) for mental health and substance use disorders
• Intensive outpatient programs (IOP) for mental health and substance use disorders

Currently, many telehealth providers cannot diagnose or test for COVID-19 and in many cases, can’t provide a "prescription" for a COVID-19 test. Local providers offering telehealth services, however, may be able to provide a referral to a testing site. Contact your primary care provider for information.

We’ve created a ready-to-share flyer you can show to your employees with more information about these providers.

Yes. Premera offers Talkspace for all our members. This is an online, virtual behavioral health provider resource. Many local mental health providers are also offering virtual services. Your patient should check with their provider first, or they can go directly to Talkspace.com/premera.

Yes. Premera-contracted providers can provide telehealth services to the extent allowed by their licensure. Members can check with their current provider office to see if they offer telehealth services.

For Medicare Advantage: CMS has loosened guidelines around telehealth services during the COVID-19 Public Health Emergency. Premera will cover telehealth visits for Medicare Advantage members billed by any healthcare facility at the same cost shares as an in-clinic visit. The previous requirement for services to be provided in certain types of originating sites and locations has been waived for the duration of the COVID-19 Public Health Emergency.

The standard allowed amount for telehealth visits is different than for brick-and-mortar (in office) visits. However, Premera is voluntarily employing CMS guidelines applicable to Medicare to reimburse for telehealth visits with brick and mortar providers at the in-office allowed amount rate. Claim costs will be no more than what would have been paid had the member been able to see their providers in person. Premera does not have a specific end date for this approach at this time, but we will continue to monitor CMS Medicare guidelines and the federal emergency period to determine the end date.

This guidance is in effect for WA group plans, FEP and Individual plans. Shared Admin groups are excluded from this guidance. Some WA Self-funded groups elected not to participate in this guidance.

Only claims for telehealth visits from providers who members normally see in-person, in-office will be processed in this manner.

Yes for certain procedures. Your dentist will be able to code your visit appropriately. This is a temporary modification; see the COVID-19 Key Dates section in this FAQ for current dates.

Effective March 25, 2020, the OIC’s second emergency order required we waive or expedite prior authorization requirements for home health care or long-term care facility services. See the COVID-19 Key Dates section in this FAQ for current dates.

The new Families First Coronavirus Response Act requires all group health plans, including self-funded plans, to provide coverage for diagnostic testing, including U.S. Food and Drug Administration (FDA)-approved COVID-19 diagnostic testing products and items and services related to testing furnished during an office, telehealth, urgent care center or emergency room visit. We have removed the group waivers that were previously in place to comply with this mandate.

Premera follows state and federal mandates related to end dates for these services. See the COVID-19 Key Dates section in this FAQ for current dates.

Commercial and Medicare Supplement members: We’re waiving in-network cost shares (coinsurance, copays, and deductibles) for members requiring FDA-authorized diagnostic COVID-19 and influenza testing. All other treatments and services including hospitalization not related to a COVID-19 diagnosis will be subject to the usual benefits and cost shares.

Pre-authorization isn’t required for medically necessary and FDA-authorized COVID-19 testing. If a member requires COVID-19 testing and treatment and there isn’t an in-network provider within a reasonable distance, the claims will be paid as in-network.

We know these are difficult times for many, and the worry about medical bills, especially as they relate to COVID-19, is great. To ease some of the burden for our members, effective today Premera will be waiving cost shares including copays, deductible and coinsurance for all COVID-19 related treatment (both inpatient and outpatient). See the COVID-19 Key Dates section in this document for current dates. 

Who is eligible for the cost share waivers for treatment?   
This benefit will apply to members of insured group, individual, grandfathered, non-grandfathered, associations and Premera’s Medicare* enrollees. Self-funded group plans have the option to participate. This includes qualified high deductible plan participants. 
This will not apply to Shared Admin, FEP, and Self-funded plans that opt-out. 

What’s being waived for treatment? 
Premera will waive member cost shares including copays, deductible and coinsurance for treatment of COVID-19 or health complications associated with COVID-19, including hospitalizations and medical transportation when needed, FDA-approved medications delivered inpatient for both in and out of network providers. 

How do you know if a treatment or hospitalization is related to COVID-19? 
Our providers are using specific claim and diagnosis codes that have been provided by various regulatory agencies. We’ll use those codes to determine if a claim is related to COVID-19. 

How is do I find out if my group is participating?    
Self-funded groups, including OptiFlex, have until noon PST on April 16, 2020 to determine if they want to opt out of the cost share wavier for COVID-19 treatment. We’ll have information about self-funded group participation by April 16, 2020. 
For Medicare Advantage members: We’re waiving all cost shares for the healthcare provider visit and FDA-authorized COVID-19 diagnostic testing for members who meet criteria for testing following CMS guidance. All other treatments and services including hospitalization are subject to the usual benefits and cost shares. 

Note: HHS announced that the COVID-19 public health emergency (PHE) will likely remain in place for the entirety of 2021. However, a PHE declaration is limited by law to a 90-day period that can be terminated early or extended. Premera will extend federally mandated benefits every 90 days upon official renewal of the PHE by HHS Secretary. The HHS will provide 60-day notice if it decides to terminate PHE or allow it to expire.

Premera will reimburse for antibody tests that are for the purpose of supporting a COVID-19 diagnosis as part of the treatment or management of a patient’s medical condition. We will not cover antibody tests that are for other purposes, such as back-to-work testing. We believe that this approach meets applicable federal law and regulations governing coverage for COVID-19 testing.

Premera has developed a Benefit Coverage Guideline that provides basic criteria to confirm that a COVID-19 antibody test has been administered to support the diagnosis of a patient’s disease or condition. The Benefit Coverage Guideline is aligned with current CDC’s guidance on the use of antibody tests in diagnosis of COVID-19. The policy will be in effect for claims with dates of service beginning July 1, 2020.

As antibody direction has continued to evolve, we’re now at a place where we have solid federal guidance on what is considered medically appropriate under the CARES Act. For dates of service through June 30, 2020, Premera will waive cost shares and cover all antibody test claims. This allows providers adequate time to be notified of our policy.  For dates of service July 1, 2020 and forward, Premera will provide coverage for COVID serology antibody testing only when medically necessary and ordered by practitioner. Premera will not cover testing when used for public health (e.g. contact tracing or surveillance testing) OR when used for return to work. Premera will cover and waive cost shares for antibody testing when used to:

• Support diagnosis when done in an inpatient setting, or
• To support diagnosis for persons who present late (9-14 days after illness onset), or
• Used for persons with complications presumed related to COVID (out-patient), such as multisystem inflammatory syndrome in children.

Premera has issued a medical policy for serology testing that is consistent with CDC’s current guidance that serology should not be used to determine immune status.

The FDA has cautioned that these serology tests should not be used as the sole basis to diagnose or exclude COVID-19 infection or to inform infection status.

Some lab companies are charging members a $10 non-refundable service fee for “physician oversight services” when a member orders testing directly through a lab. The $10 fee is for an independent physician who orders test for the member. The member also has the option to consult with this physician to discuss their results. This fee is not submitted to insurance for reimbursement by the lab service or the physician. This type of service fee and claim are not covered by the medical plan. To avoid this type of service fee, members should use their own provider or clinic when requesting COVID-19 testing.

Premera recognizes that our members have concern as to whether or not they may have/had COVID-19. However, it is up to the doctor's determination/evaluation to whether the member met the criteria for testing/diagnosis based upon guidelines set by the CDC. If the doctor determines the member does not meet the CDC criteria for testing/or workup of possible or diagnosed COVID-19, then cost share waivers will not be applied. We continue to outreach to providers on COVID-19 related billing practices.

Yes, this comprehensive approach means that Premera members nationwide will have easier access to medications and testing. These benefits are based on the state the plan was sold in, not where the member resides.

Additionally, all 36 participating Blue Cross Blue Shield plans across the country are implementing similar approaches to show their collective support.

COVID tests for travel aren’t covered typically by the plan. This will not apply to Shared Admin, Commercial, Medicare Advantage and most self-funded plans. Normal plan benefits apply in this situation for our members. FEP and some self-funded plans are covering testing for travel. You can check eligibility and benefits on our website.

We won't include testing coverage (molecular/antigen or antibody tests) for return-to-work/return-to-school strategies for our insured book of business just as we don’t cover drug testing for employment purposes, as an example. The EEOC has clarified (see A.6) that any mandatory medical test is job related and consistent with business necessity. They have also recommended that employees consent in writing acknowledging that a molecular test done for return-to-work purposes is not a diagnostic test.

Premera will continue to monitor the science and will be ready to launch solutions that feature meaningful testing if and when that becomes available.

Ultimately, it’s your decision as a self-funded plan sponsor, and if, after considering all this, you are still convinced you want to cover testing, Premera will work with you to administer that charge.

Yes, all changes to our insured business apply to Peak Care. MultiCare has also established three respiratory clinics across the region that are by appointment only, as opposed to walk-in visits. They offer COVID-19 testing and additional testing for respiratory issues based on the provider's assessment. Any Peak Care member has additional access to MultiCare’s free e-visits to anyone who has COVID-19 symptoms through their Virtual Care, where their providers will help them navigate to the next appropriate step, if testing for COVID-19 is warranted. Use promo code “COVID19” at the payment page to unlock the free e-visit after completing their protocol.

It’s your decision as a self-funded plan sponsor, and if, after considering all this, you are still convinced you want to install a program that includes testing, Premera may work with you to administer the plan.

Yes. Drive-through testing (tents) for COVID-19 is covered and cost shares will be waived as they are for in-clinic testing.

FDA-authorized COVID-19 Home Test Kits are only covered when ordered by a licensed physician or pharmacist. Home Test Kits will not be covered if used for non-diagnostic purposes (e.g., travel, return to work, etc.). Members may submit claims for reimbursement for in-home tests only when they are ordered by a physician or pharmacist. There may also be tax implications for using HSA funds to purchase in-home tests that are used for purposes other than diagnostic.

The IRS issued guidance allowing COVID-19 testing and treatment cost-share waivers for high deductible health plan and non-high deductible health plan members.

We currently have processes in place to pay government hospitals such as VA facilities and pop-up military hospitals. We are prepared to process claims if necessary. At this time, we have indicators that these facilities may not bill, but are still working to confirm. Many of these facilities will be covering care not related to COVID-19 to help alleviate the burden on facilities as they care for COVID-19 related patients.

Based on the claims we’ve received as of April 7, the average cost for testing is $42, which doesn’t include charges for the associated office or ER visit.

We encourage members to call their providers if they suspect they’ve been exposed to COVID-19 or if they’re experiencing flu-like symptoms. If you do go to the doctor, make sure to call first so they can prepare for your arrival.

If you have symptoms like a cough, fever, or other respiratory problems, call your doctor first. Do not go to the emergency room. Emergency rooms need to be able to serve those with the most critical needs. If you have difficulty breathing, it doesn't mean you have COVID-19, but you should call 911 if it’s serious.

24-Hour NurseLine or other telehealth services may be included in your benefits and are also excellent resources if you’re concerned about your symptoms. Many providers offer telehealth services by phone or video chat. Ask your provider if they offer these services.

When PPE is worn as part of a dental, medical or pharmacist healthcare visit, it’s considered part of the practice expenses included in the main dental medical or pharmacy related procedure rendered to a patient. PPE will not be separately reimbursable.

Premera doesn’t cover employment-based services, such as return-to-work/school testing or drug testing. If you have an employee that you require to be tested for COVID-19 before they return to work/school, you can have the employee tested at any clinic or provider office offering the test. The bill (claim) shouldn’t be submitted to Premera and instead should be billed directly to you as the employer.

For members who are out of country: Standard Premera plans don’t cover medical evacuation or repatriation to those overseas who may become ill.

For members within the U.S.: Plans cover ambulance transport for a medical emergency, when a person’s health is in serious danger and an ambulance is the only safe way to get to the closest medical facility equipped to treat their condition. Emergency transport is subject to the usual benefits and cost shares Transport from a hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or physician isn’t considered medically necessary.

Currently, COVID-19 is treatable at many facilities. In the event a patient is transported by ambulance to an emergency department due to COVID, eligibility for benefits will be reviewed for cost share waivers.

As long as the member is still eligible and has the Blue Cross Blue Shield Global Core program (formerly known as BlueCard Worldwide^®) they should be covered outside the United States. Members should look for the suitcase logo on their ID card and can call the number on the back of their card to be connected for services out of the country.

With Global Core, Premera applies the benefits and coverage determination and approves payment. BCBS Core works with the provider in other countries to set up guarantee of payments. Members must call the number on the back of the card to set up a guarantee of payment.

You can access proof of coverage from your Premera.com account. Your online benefit booklet has proof of coverage that can be printed and used for your travel.

The CDC recommends that travelers at higher risk for COVID-19 complications avoid all cruise travel and non-essential air travel. We highly recommend that members work with their healthcare provider to come to a care decision that balances risks and expected outcomes with their preferences and values.

For PDCOE, a key element of that program is to identify and outreach to encourage eligible members to travel to our identified high value specialty care providers. Since travel is a concern and many facilities are cancelling elective procedures, we are temporarily ceasing targeted outreach letters and calls for all lines of business. If a member wants to pursue medical travel, our customer service team's personal health clinicians are available to help.

For elective medical travel, we recommend that members work closely with their healthcare providers to determine if travel is recommended and safe. Many hospitals are delaying elective surgeries due to COVID-19, and procedures may be delayed to ensure staff and patient safety. The elective medical travel benefit remains available to members for all approved travel.

Yes. We’ve adjusted our refill too soon policy for medications. This allows pharmacies to override refill too soon edits during a declared emergency at the pharmacy counter. See the COVID-19 Key Dates section in this FAQ for current dates.

90-day refills:

• Most plans have access to mail-order prescriptions. Ask your provider about getting a 90-day supply.
• Medicare Advantage members: Use this mail-order form.
• Medicare Supplement members: If you have a separate Part D prescription drug plan, contact your Part D plan administrator for more info.

Some telehealth providers have also temporarily waived their refill policies prohibiting the refill of chronic medications beyond twice in a calendar year. Providers will consider clinical appropriateness, patient safety and professional judgement.

Note: Some prescriptions aren’t eligible for mail order. Members should check their plan benefits or contact customer service at the number on the back of their ID card.

Currently, controlled substances are not carved out. Pharmacies can override the refill too soon edit at the point of sale by entering a submission code. The dispensing pharmacist will review the need to override refill too soon rejections on controlled substances (such as opioids and benzodiazepines) by working with the prescriber.

Yes. The Premera pharmacy network maintains rigorous safety standards for inventory and follows guidance from multiple regulatory agencies (including the FDA, CDC, and U.S. Preventive Services Task Force) to ensure drugs are approved by the FDA for the U.S. market. All drugs approved for use in the U.S. must meet FDA-manufacturing standards to assure quality and product label requirements.

We frequently see drug shortages in the U.S. based on manufacturer issues, raw product issues, etc. We may see new reported shortages based on the COVID-19 impact to Chinese manufacturers.

Premera will respond to these shortages the same way we do today, by ensuring the following:

• The pharmacy team will check public and industry resources to identify new shortages that may impact our members.
• We’ll review medical policies to determine if adjustments are needed to ensure access to alternative medications (should we change our preferred drugs or update prior authorization criteria to account for shortages both short and long term).
• Our review processes already account for drug shortages. If a drug we require as first-line therapy is in short supply, we’ll waive this requirement based on market realities and approve coverage when preferred formulary alternatives are in short supply.

We’re also reviewing rejected claims to see if members are getting the medications they need. If we see any drug shortages, we’ll seek other options to meet member needs. We’ll continue to monitor the situation with our pharmacy partners, so members won’t run out of needed medications.

Premera has been covering chloroquine and hydroxychloroquine since March, 2020 as they had Emergency Use Authorization from the FDA for COVID treatment. However, on Monday, June 15, the US Food and Drug Administration revoked its emergency authorization of chloroquine and hydroxychloroquine stating they were unlikely to be effective in treating COVID-19. In addition to not helping treat the disease, the drugs were linked to "serious cardiac adverse events and other serious side effects. These drugs still have an indication for other conditions (e.g. lupus, rheumatoid arthritis, malaria) and will continue to be covered for these uses. Quantity limits for new starts on these medications will remain in effect.