At Premera, you'll discover smart ways to get the right care when and where you need it. You can also learn all about what we're doing to improve the quality of the care you receive. Plus, you'll find information about the industry leading ways to keep your personal information safe. And there's much more:
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.
Primary care providers include family doctors, internal medicine doctors, pediatric doctors, physician assistants, and nurse practitioners. You’ll find a list of in-network primary care providers in our online “Find a Doctor” directory. Customer Service can also help you find physicians, dentists and hospitals in your area and provide details about their services and professional qualifications.
While you are not required to select a primary care physician, these practitioners can assist you to maintain and monitor your health and access the services of specialty care physicians.
Have you changed plans? Is your healthcare provider no longer in-network?
Use the Transition of Care Worksheet to see if you can continue your care with your present healthcare provider at the in-network level.
Did you know that the following tests and treatments are often not needed and may be harmful to your health?
Check out Choosing Wisely: When to say ‘Whoa!’ to doctors to learn more.
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.
The Quality Program works to measure evaluate and improve your health and the quality and safety of the care and service you receive as a Premera member. To do this, we work with the people, facilities, and community organizations that organize, support, and deliver medical and behavioral health care and service. We encourage doctors to practice safe, evidence-based medical and behavioral health care, encourage members to receive the preventive, acute, and chronic care they need and work to improve the service we provide as a health plan. We also evaluate complaints, problems getting care and service, member and provider satisfaction, and communication to determine if improvement is needed. At Premera, members of our Board of Directors, company leaders, managers, and associates contribute to the Quality Program through its committees and activities. Quality measurement and improvement is planned and tracked monthly and the Quality Program is evaluated annually.
Progress we've made in improving care and health
Progress we've made in improving service
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. The links below 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:
Learn more at: www.npsf.org/askme3
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 personal health support to you or your family members who have the following chronic health conditions:
This service is voluntary and is offered at no extra cost to you as part of your health plan. We identify members who may be eligible for this program through review of claims and by referrals from doctors and healthcare providers. If you have one of the above conditions, you may be automatically enrolled in this service.
Once enrolled, you’ll receive quarterly newsletters with information on how to improve your health. You may also be eligible for a dedicated Personal Health Support Coach. Our health coaches are nurses, dieticians, social workers and counselors who can help you identify the barriers to good health and help you better understand your condition.
If you wish to discontinue this service, or you would like more information about it, you can call one of the numbers below.
How to Ask for HelpYou may refer yourself or a family member by calling:
Or email us at PersonalHealthSupportCoach@Premera.com.
More information on Diabetes:
More information on Asthma:
More information on COPD:
More information on Coronary Artery Disease (CAD):
More information on Heart Failure:
Case Management offers support to help you or a family member with serious health problems. With this service, a nurse or a clinical case manager 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 case.management@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 prior authorization, and it helps you:
Learn more about prior authorizations
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.