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Premera’s medical plans do not cover all health care expenses and include limitations and exclusions. Please refer to your benefit booklet to determine which services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan may contain exceptions to this list based on state mandates, essential health benefits, or the plan design purchased.
View the summary of benefits and coverage.
Primary care providers include family doctors, internal medicine doctors, pediatric doctors, doctor assistants, and nurse practitioners. You'll find a list in our online Find a Doctor directory. Sign into your online account to search for doctors contracted with your specific plan. Customer Service can also help you find physicians, dentists and hospitals in your area and provide details about their services and professional qualifications.
Depending upon your plan, you may be required to select a primary care provider. Sign into your online account and refer to your member benefit booklet for details about your specific plan. Even if your plan does not require selection of a primary care provider, these practitioners can assist you to maintain and monitor your health and access the services of specialty care providers.
We design our provider networks carefully. You can learn more about how we do so in the Network Design Criteria for Practitioners.
Members may seek specialty care and behavioral healthcare from in-network or out-of-network providers. Be sure to talk with your primary care provider about your preferences. Depending on your plan, you may need a referral from your primary care provider in order to access specialty care. Refer to your member benefit booklet for details.
Participating in-network providers and facilities are listed in our online Find a Doctor directory. Certain non-emergency hospital and other medical services require pre-approval from Premera. Customer service can assist you with the directory or help you locate a practitioner or facility within a specific geographic area.
Please note: If you are enrolled on an EPO plan, in most cases you are only covered for services from in-network providers. Sign into your online account and refer to your member benefit booklet for details.
Did you know that the following tests and treatments are often not needed and may be harmful to your health?
You have options if you need after office hours or emergency care. Sometimes it's hard to know what to choose, but there's a big difference in time and money.
Call our FREE and CONFIDENTIAL 24-Hour NurseLine to speak with a registered nurse who will ask the right questions, listen to your concerns, and help you determine where and when to seek treatment. The NurseLine number is listed on the back of your ID card. Note: if there isn't a NurseLine number on your card your plan may not participate with the NurseLine service.
Urgent care facilities provide quick, convenient care for health needs that aren’t life threatening but can’t wait until the next day or longer. They are open outside of regular business hours and are less expensive than emergency room care. To locate the nearest urgent care facility, search our find a doctor directory (choose “Facilities by Specialty” then select “Urgent Care” specialty).
Conditions that can be dealt with in an urgent care facility:
Call 911 or go to the emergency room if you are in severe pain or your condition is endangering your life. To locate the nearest ER, search our find a doctor directory.
Examples of medical emergencies:
Premera members have access to a comprehensive, nationwide network of retail pharmacies and access to a convenient mail order pharmacy, Express Scripts Home Delivery. To find information about your drug benefits use the following links.
Find a network pharmacy near you:
View pharmaceutical management procedures (procedures that affect your drug coverage):
View your drug list and see which drugs have limitations to prescribing or access:
Learn how to obtain restricted pharmaceuticals:
Premera and its delegates do not reward or pay our staff based on how members use healthcare services. We do not base their pay in any way on how or if they decide to approve or deny coverage. We do not reward or pay our staff to make decisions that cause members to use fewer healthcare services.
We do review some healthcare services before members get them. These reviews help us decide if and how to cover those services. When we do a review, we look only at whether services meet medical criteria for your condition and whether your plan covers them.
“We” includes Premera and any of its delegates, any people or organizations we hire to review requests.
Teams of doctors, pharmacists, and nurses review new drugs and medical services. The Medical Policy Committee reviews new technology and other medical or surgery services. The Pharmacy and Therapeutics Committee reviews new drugs and some therapies. These committees decide if a new drug or service will be covered. Their decisions are based on sound published medical studies. Their decisions help protect against the use of treatments that are not proven or not safe.
It's important to think about safety when you need health care. Communication with your doctor is perhaps the most important link to better care and health outcomes. These links provide useful tools to help you communicate with your doctor about care and medications.
For a Medication List in English and Spanish and a variety of Tips and Tools related to medications, go to: http://www.safemedication.com
Asking questions is important to safe care! The Agency for Healthcare Research and Quality provides useful resources including The 10 Questions You Should Know
The Ask Me 3™ is a program designed to promote communication between health care providers and patients in order to improve health outcomes. The program encourages patients to ask and understand the answers to three questions:
A patient safety fact sheet tells what you can do to ensure safer health care, “Five Steps to Safer Health Care” is available from the
Agency for Healthcare Research and Quality.
Premera offers help to support to our members and their spouses/domestic partners, and dependents who are enrolled in a Premera plan and are diagnosed with a chronic condition such as asthma, coronary artery disease, heart failure, chronic obstructive pulmonary disease, diabetes, or depression.
Premera offers a personalized, one-on-one support program to help you manage your condition. The program encourages healthy lifestyle changes and the development of self-management strategies for better health. This program is available at no cost to you.
Tools and resources include:
Participants have access to a personal health support team of registered nurses, certified dietitians, and licensed mental health professionals with expertise in chronic condition management.
Participation is voluntary, and you can withdraw at any time.
3 ways to join:
Premera offers home based care to eligible members provided through Landmark. Landmark is a full-service medical group that provides medical care in the comfort of your home, whenever you need it. Board-certified doctors, nurse practitioners and physician assistants are experts in house calls and collaborate with your primary care provider, so you can continue to see the doctor you know and trust. Landmark practitioners can provide in-home care for most issues, including urgent care needs. They can even prescribe a drug if necessary.
How to ask for help:
Landmark provides home-based chronic care in the state of Washington in Snohomish, King, Pierce, Thurston, and Spokane counties. Providers are available 24 hours a day, 7 days a week. You can contact Landmark directly at 877-260-7647, or online.
Eligible members who have enrolled with Landmark home-based care services can opt out of the service at any time by contacting their customer service representative at Premera or Landmark directly.
Coronary Artery Disease (CAD):
Personal Health Support offers support to help you or a family member with serious health problems. With this service, a nurse or a Personal Health Support services clinician will help you with any concerns you have with your health or healthcare. This service is voluntary and free as part of your health plan.
How to Make a Referral
You may refer yourself or an eligible family member for case management services. Call 888-742-1479 or email us at HealthHelp@premera.com
Don’t be surprised by a bill you weren’t expecting
Did you know that you may be required to get an approval for coverage from your health plan before you have a planned medical service or procedure? This is called a pre-approval, and it helps you:
Learn more about pre-approvals
These are your rights as a health plan member.
These are your responsibilities as a health plan member.
When you receive care from providers in the network, they will process your claims directly with us, so you don't need to handle any paperwork. However, if you receive care from a non-network provider, you may have to pay the provider for the service and then file a claim with us for reimbursement.
To file a claim for reimbursement, simply follow these steps:
Please see your Benefit Booklet for more details on filing claims.
If you disagree with how a claim was paid ─ as described on your Explanation of Benefits (EOB) ─ you can request a review. We must receive your request to review a claim within 180 days after you receive your EOB. You can either call Customer Service or submit a written request. If you suspect that payments were made for services you didn't receive - please call the Anti-Fraud Hotline at 800-848-0244.
If you prefer, you can submit a written request so you can make a copy for your records. Along with your written request, include a copy of your EOB to identify details of the disputed claim and any other documents or information that may help resolve your claim to your satisfaction. After we receive your request, we'll send you detailed information about our appeals process, including the timeframes for each step of the process. Send your request to:
Premera Blue CrossAttn: ClaimsP.O. Box 9105 Seattle, WA 98111-9159
Please contact Customer Service.
Please note: Some groups may have a different contact phone number. Please confirm your contact number on the back of your ID card before calling. For more detailed information about your benefits, see your contract or Contact Us.
You can make complaints about:
You also have the right to appeal any action we take or decision we make about your coverage or services.