Understanding My Health Plan

Medical

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.

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

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?

• Imaging tests for a headache or lower back pain,
• EKG
• Bone-density tests
• Pap tests
• Antibiotic treatment for sinusitis
• Proton pump inhibitor (PPI) treatment for heartburn

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.

24-Hour NurseLine

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.

Non-Life Threatening

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

• ear infections
• low fever or mild flu symptoms
• minor rashes, cuts, bites and sprain

Life Threatening

Call 911 or go to the emergency room if you are in severe pain or your condition is endangering your life. To locate the nearest ER, search our find a doctor directory.

Examples of medical emergencies:

• suspected heart attacks
• strokes
• broken bones

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:

• Find an in-network pharmacy

View pharmaceutical management procedures (procedures that affect your drug coverage):

• View drugs that require Pre-approval (exception requests)
• Learn how to obtain coverage for non-drug list drugs if you have a closed drug list plan
• View drugs subject to Pre service review
• Learn what Premera does to keep costs down

View your drug list and see which drugs have limitations to prescribing or access:

• Search drug lists with Rx Search
• Visit Express Scripts to view your personalized pharmacy benefits

Learn how to obtain restricted pharmaceuticals:

• Use Rx Search to learn which drugs have restrictions, quantity limits and step therapy
• Visit Express Scripts to find your copay for a restricted prescription
• Learn about prescription mail-order

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.

• Safety Information

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

• Medication list

For a Medication List in English and Spanish and a variety of Tips and Tools related to medications, go to: http://www.safemedication.com

• 10 questions to ask

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

• Ask Me 3™

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:

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

• 5 Steps to safer care

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:

• Diabetes
• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Coronary Artery Disease (CAD)
• Heart Failure

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 these conditions, you may be automatically enrolled in this service.

Once enrolled, you'll receive twice a year 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, contact us at:

• 866-756-2050
• 888-517-3508 TTY/TDD for the hearing impaired

How to ask for help

Members may self-refer or refer a family member by calling 888-742-1479 or email us at PersonalHealthSupport@Premera.com.

More information on Diabetes:

• diabetes.org
• cdc.gov/diabetes
• nih.gov/about/discovery/chronicdiseases/diabetes.htm
• win211.org

More information on Asthma:

• lung.org
• nhlbi.nih.gov
• cdc.gov/asthma
• win211.org

More information on COPD:

• lung.org
• goldcopd.org
• nhlbi.nih.gov
• cdc.gov/cop
• win211.org

More information on Coronary Artery Disease (CAD):

• cardiosource.org
• heart.org
• nhlbi.nih.gov
• win211.org

More information on Heart Failure:

• cardiosource.org
• heart.org
• nhlbi.nih.gov
• win211.org

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

Make sure you’re covered

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:

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

Learn more about pre-approvals

These are your rights as a health plan member.

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

These are your responsibilities as a health plan member.

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

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:

• Complete and sign the form.
• Staple an itemized bill from the provider for the covered service.
• Mail your claim to the address shown on the form.

Please see your Benefit Booklet for more details on filing claims.

Request a Claim Review

If you disagree with how a claim was paid ─ as described on your Explanation of Benefits (EOB) ─ you can request a review. We must receive your request to review a claim within 180 days after you receive your EOB. You can either 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.

Submit a Written Request

If you prefer, you can submit a written request so you can make a copy for your records. Along with your written request, include a copy of your 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 Cross
Attn: Claims
P.O. Box 9105
Seattle, WA 98111-9159

Questions? Concerns?

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:

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

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