Premera Blue Cross Response to COVID-19

  • Premera Blue Cross is here to support members, employers, and healthcare providers during the coronavirus (COVID-19) outbreak.

    Updates as of August 31, 2021

    • New questions added to the Group Eligibility and Premiums section
    • The FDA approved the Pfizer-BioNTech COVID-19 vaccine for individuals 16 and older on August 23, 2021.
    • A third COVID-19 vaccine dose was recommended for certain individuals. There are specific codes to use for these doses.
    • The federal Public Health Emergency was extended another 90 days to October 18, 2021. See the COVID-19 key dates grid for details.

    For general questions about COVID-19:
    Washington State Department of Health
    Centers for Disease Control and Prevention

    The Association of Washington Business has an employer resource list you may find helpful.

    If you have health plan questions not covered in these resources, call our customer service team at the number on the back of the member ID card, or your assigned account manager.

    We’ll be updating the following FAQ as additional information is available.

    COVID-19 Key Dates

    COVID-19 Coverage
    See related section for more information about health plan coverage.
    End Date
    Cost share waivers for FDA-approved COVID-19 diagnostic testing other virus/respiratory testing tied to a COVID-19 diagnosis (federal Families First Act and Washington State OIC mandate) October 18, 2021*
    Antibody tests covered when done in an inpatient setting; late illness onset, or outpatient inflammatory syndrome in children. Cost shares waived if criteria met. (CDC and EEOC guidelines) Policy effective July 1, 2020.
    Cost share criteria through October 18, 2021.*
    Applied behavioral analysis (ABA) available through telehealth (Premera initiative) December 31, 2021
    PHP and IOP available through telehealth became policy:
    • Partial hospitalization programs (PHP) for mental health and substance use disorders
    • Intensive outpatient programs (IOP) for mental health and substance use disorder
    • Telehealth policy updated to allow ongoing coverage effective January 1, 2021.
    Policy effective January 1, 2021
    Medicare Advantage members: cost shares waived for the healthcare provider visit and FDA-authorized COVID-19 diagnostic test for members who meet criteria for testing (CMS guidance) October 18, 2021*
    Waiver of prior authorization requirements for home health care or long-term facility services (Washington state OIC mandate) July 25, 2021
    Allowance for certain procedures to be handled through tele-dentistry became policy. (Premera initiative) Policy effective April 1, 2021

    *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.

    COVID-19 vaccines

    Note: We’re updating our vaccine FAQs as information becomes available. Information about vaccines and distribution will continue to evolve.

  • On August 23, 2021, the FDA approved the Pfizer-BioNTech COVID-19 vaccine for individuals 16 years of age and older. The vaccine continues to be available under Emergency Use Authorization for individuals 12-15 years of age and for the administration of a third dose in certain immunocompromised individuals. The other two vaccines, Moderna and Johnson & Johnson, continue to have Emergency Use Authorization for individuals 18 and older.

    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 U.S. Food and Drug Administration (FDA) expanded the emergency use authorization (EUA) for the Pfizer-BioNTech COVID-19 vaccine for the prevention of COVID-19 to include adolescents ages 12 to 15. 

    On May 11, the Biden Administration announced a partnership with both Lyft and Uber to offer free rides to vaccination sites to those in need. You an access the information and request a free ride through Uber and Lyft websites.

     

    Washington state has approved the use of the Pfizer COVID-19 vaccine for adolescents ages 12 to 15 starting May 13, 2021. All Washington residents age 12 and older are now eligible for the vaccine.

    View WA state guidance. Use the Washington Department of Health Vaccine Locator tool to find locations offering the COVID-19 vaccine and to see eligibility information.

    If you need homebound vaccination services or know of someone who needs this service in the state of Washington, check out these resources:

     

    • Call your local health jurisdiction for homebound vaccination services.

     

    • Call Washington state’s COVID-19 Assistance Hotline to let them know you need homebound vaccination services. Call 800-525-0127 or 888-856-5816, then press #. Phone interpretation is available.

     

    • Use this survey link to complete a registration form that will connect you to available county and/or state mobile vaccine teams.

    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 federal government has mandated that the cost of the vaccine will be $0 for everyone in the U.S. The cost for administering the vaccine will be covered by insurance, for those with coverage, or waived for those without coverage. Providers may bill an insurance company for administrative costs. We’re waiting for final costs to be delivered, which may vary based on location and state-by-state.

    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.

    Outside of Washington state, the CDC website has information on each state. Go to "How do I get a vaccine?" and select your state.

    Here is information for Washington state:

    • Use Washington state’s online tool at findyourphasewa.org. Bring your patience as the website sometimes gets overwhelmed.
    • The Washington state Department of Health (DOH) has a map and list of where you can get vaccinated. Be sure to call the location to verify that they do have vaccines available, as it changes daily.
    • People without internet access can call DOH at 800-525-0127, press #, or 888-856-5816. Be patient, the phone line is often flooded with calls.

     

    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.

    The Pfizer-BioNTech COVID-19 vaccine is available for adolescents aged 12 to 15. Moderna and Johnson & Johnson are approved for those 18 and older. Studies to test COVID-19 vaccines are beginning for those under the age of 12.

    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.

    The Centers for Disease Control and Prevention (CDC) officially recommended the administration of a third vaccine dose from Pfizer/BioNTech or Moderna for many individuals, including patients who have been receiving active cancer treatment for tumors or blood cancers, those who have received organ transplant or stem cell transplant, and those with moderate or severe primary immunodeficiency. Health plans will continue to cover all vaccine administrative costs for their members as required. We anticipate a third dose will be approved for fall and will follow the same phased roll-out as with the initial vaccines.

     

    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.

  • Frequently asked questions about COVID-19 and health plan coverage

    Group eligibility and premiums questions

  • Premera does not have plans to impose a surcharge. The decision to apply a surcharge is complicated and the options and ability to impose a surcharge differs based on the line of business and whether the product is fully insured or self-funded.

    Also, the Affordable Care Act does not permit insurers to consider health factors in determining premium rates. This means that premium rates cannot differ based on health factors or conditions.

    In Washington state, our regulator, the Office of the Insurance Commissioner, issued a public statement that they believe that surcharges imposed on unvaccinated members are illegal. Specifically, they state their interpretation is that unvaccinated members may not be charged more than vaccinated members. 

    No. Rates are required to be filed and approved prior to a product being sold. Once a rate is approved, we are not permitted to adjust the rate mid-year. Individual rates may be impacted in subsequent years based on whether costs have increased due to utilization and other factors. In the future, the costs related to COVID-19, including hospitalization for unvaccinated members will be a factor in ratemaking. The rates will be adjusted appropriately to account for these costs at that time.

    The Affordable Care Act and other federal laws prohibit insurers from charging more for people who are not vaccinated.

    There is no clear legal roadmap to charging unvaccinated employees higher premiums. The law regarding non-discriminatory premium charges is complicated and has many overlapping requirements. Even if an employer is able to overcome the complicated web of laws and regulations, there are other issues to contend with, including – how would a premium difference be determined based on sufficient actuarial data that determines the cost differential between vaccinated and unvaccinated employees or how will the business decide if a person is not medically able to receive a vaccine and avoid disability discrimination under the Americans with Disabilities Act (ADA)?

    Fully insured employers: Because of concerns around discrimination and the restrictions on charging certain enrollees more based on health status or condition, fully insured groups will not be able to impose a surcharge. In the future, rates may be able to take into consideration the costs associated with unvaccinated members, and we can rate for experience. There are still concerns about trying to rate based on vaccine status now and it would not be advisable for many reasons including: (1) we do not have complete data around vaccination status and (2) we do not yet have the claims experience to make the connection.

    Self-funded employers: Generally, self-funded employers can make decisions about the administration of their group health plans as they are the plan fiduciaries. We require employers with self-funded health plans to seek independent legal advice about decisions such as imposing a surcharge on unvaccinated employees. HIPAA and ERISA non-discrimination rules apply to these health plans, so there may be a risk to imposing such a fee.

    Note: For employer groups on fiduciary option contracts, we have agreed to take on additional fiduciary obligations. Those groups will not be able to impose a premium surcharge. 

    Outside of a health plan, employers can impose higher costs on people who are unvaccinated through wellness programs. Similarly, employers can impose incentives or penalties. There are still many federal laws to prohibit discrimination against protected classes of disabilities as well as those with pre-existing medical conditions in wellness programs. A vaccine surcharge needs to comply with the HIPAA and ACA rules related to wellness programs.

    Current Equal Employment Opportunity Commission (EEOC) guidance released on vaccines mandates would apply to the surcharge, specifically that the surcharge cannot be so high as to be “coercive,” and employers must provide an accommodation to those who are unable to get vaccinated due to a disability or sincerely held religious belief. So, even this approach carries some risk and employers need to get independent legal advice before moving forward with these types of programs.

    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.

    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.

    The option for self-insured and OptiFlex groups to waive the LOA and actively at work requirements ends on June 30, 2021.

    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 may meet the Washington Health Insurance Market place special enrollment criteria if they don’t meet eligibility requirements on their group plan. 

    On April 29, 2020, the U.S. Department of Labor (DOL) announced guidance which extends a number of regulatory deadlines for ERISA plans and plan participants. In March 2021, new guidance was issued that keeps an extension in place but clarifies that the maximum amount of additional time allowed on any deadline will be 1 year.

    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.

    The U.S. Department of Labor (DOL) along with the Internal Revenue Service (IRS) issued a joint final rule extending specific deadlines affecting COBRA continuation coverage, special enrollment periods, claims for benefits, appeals of denied claims, and external review of certain claims. 

    Starting March 1, 2021 on a person by person/claim by claim basis, we are required to allow an amount of additional time that is lesser of: (a) 1 year from the date when a person’s timeframe ‘started’, or (b) until 60 days after the announced end of the National Emergency.

     

    • New guidance released by the DOL changes how the timeframe extensions under the previous DOL notice operate. The previous guidance paused the clock on particular timeframes for elements of COBRA, SEPs, and claims and appeals filings. This guidance keeps an extension in place but clarifies that the maximum amount of additional time allowed on any deadline will be 1 year.

    • Starting March 1, on a person by person/claim by claim basis, we are required to allow an amount of additional time that is lesser of: (a) 1 year from the date when a person’s timeframe ‘started’, or (b) until 60 days after the announced end of the National Emergency.

    • Timeframes will begin to run again on a rolling basis. With respect to group health plans and their sponsors and administrators, the Outbreak Period shall be disregarded when determining the date for providing a COBRA election notice.

    • Employers should review the DOL’s Frequently Asked Questions on health benefit and retirement benefit issues related to COVID-19. These FAQs 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. You can review the DOL’s COBRA Model Notice FAQ.

    Those not subject to ERISA may not be required to comply with this rule. Groups not subject to ERISA (e.g., church or government plans) and plans not subject to ERISA (e.g., Dependent Care Assistance Programs (DCAP) and Health Savings Accounts (HSA) or Commuter benefits) may not be required to comply with this Rule. You should consult your legal and benefits advisors to determine what impact this rule has on your plans. 

     

    We will continue to allow retro-enrollment up to the lesser of 1 year or 60 days after the end of the outbreak period as long as the effective date requested is appropriate for the enrollment reason. We will not term anyone for non-payment during that same timeframe. 

     

    Employers can choose to allow qualified beneficiaries to enroll in coverage that is different from the coverage they had at the time of the COBRA qualifying event. The American Recovery Plan provides that changing coverage will not cause an individual to be ineligible for the COBRA premium assistance, provided that:

     

    • The COBRA premium charged for the different coverage is the same or lower than for the coverage the individual had at the time of the qualifying event;

     

    • The different coverage is also offered to similarly situated active employees; and

     

    • The different coverage is not limited to only excepted benefits, a QSEHRA, or a health FSA.

     

    If the employer permits individuals to change coverage options, the employer must provide the individuals with a notice of their opportunity to do so. Individuals have 90 days to elect to change their coverage after the notice is provided.

     

    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.

  • Virtual care benefits

  • 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.

    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.

  • Prior authorizations

  • 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.

  • COVID-19 benefits and testing

  • The IRS just issued guidance that the amounts paid for personal protective equipment (PPE) to prevent the spread of COVID-19 (such as face masks, and sanitizer and sanitizing wipes) are deductible medical expenses and eligible to be paid/reimbursed under health flexible spending arrangements (health FSAs), Archer medical savings accounts (Archer MSAs), health reimbursement arrangements (HRAs), or health savings accounts (HSAs). 

    The new Families First Coronavirus Response Act requires all group health plans, including self-funded plans, to provide coverage for provider-ordered 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 provider-ordered 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 provider-ordered 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.



    While cost shares, including copays, deductibles, and coinsurance for all COVID-19 related treatment (both inpatient and outpatient) ended on June 30, 2021, treatment costs are still covered as a medical expense. See the COVID-19 Key Dates section in this document for current dates. 

    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.

    Molecular/antigen testing

    Serology/antibody testing

    The FDA approved two types of tests for diagnosing COVID-19 — molecular and antigen.

    Molecular test: This test detects genetic material of the virus using a lab technique called polymerase chain reaction (PCR). Also called a PCR test.

    Antigen test: This newer COVID-19 test detects certain proteins that are part of the virus. Using a nasal or throat swab to get a fluid sample.

    • Done to determine if person presenting with symptoms has COVID-19.
    • Typically a nasal swab or saliva sample.
    • Covered for diagnostic purposes when ordered by a provider.
    • Both may be offered as a “rapid” test
    • Not covered/not medically necessary for RTW/RTCampus support or other public health purposes.
    • For persons who present 9-14 days after illness onset, serologic testing can be offered in addition to recommended direct detection methods such as polymerase chain reaction.
    • Not medically necessary for diagnosis.
    • Not covered/not medically necessary for RTW/RTCampus support or other public health purposes.

    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 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.

    Recent Washington state legislation allows for medical practitioners to bill Premera for incurred personal protective equipment expenses as a separate expense up to $6.57 for each individual patient encounter. This bill is now in effect for dates of service beginning April 16, 2021, for the duration of the federal public health emergency related to COVID-19. Providers may not balance bill members for any additional PPE costs.

    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.

  • Pharmacy benefits

  • 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.

    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.

    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 U.S. 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.