Premera Blue Cross Response to COVID-19

Pfizer-BioNTech vaccines are available to people ages 6 months and up. A Moderna vaccine is available for people ages 6 months and up.

The Novavax vaccine was given Emergency Use Authorization (EUA) approval on July 20, 2022 for people ages 18 and up. It’s a 2-dose series given 3 weeks apart. It’s similar to the same protein base used in flu shots, instead of the mRNA base used in the Pfizer and Moderna vaccines.

Janssen COVID-19 vaccine is only recommended for certain individuals. Read the CDC information about appropriate use of the Janssen vaccine.

Health plans will continue to cover all vaccine administrative costs for their members as required, while Centers for Medicare & Medicaid Services (CMS) said Medicare will reimburse providers for vaccines through the current PHE.

New bivalent boosters are available from Moderna and Pfizer. The current monovalent boosters should only be used in children who are too young to receive one of the bivalent boosters.

A Pfizer-BioNTech monovalent vaccine is authorized for children 6 months-11 years and a Moderna vaccine was authorized for children 6 months-17 years.

Children need a 3-dose Pfizer primary series or a 2-dose Moderna primary series.

A new Novavax booster vaccine dose was authorized for people ages 18 and older. New codes apply.

A new Moderna bivalent booster vaccine dose was authorized for people ages 12 and older. New codes apply.

Pfizer-BioNTech vaccines are available to youth ages 5-17. A Moderna vaccine is available for youth ages 6-17. A Moderna booster vaccine dose was authorized for youth ages 6-17. This is in addition to the Pfizer booster dose already authorized for children 5-17.

A Pfizer-BioNTech vaccine was authorized for children 6 months-4 years and a Moderna vaccine was authorized for children 6 months to 5 years.

Children need a 3-dose Pfizer primary series or a 2-dose Moderna primary series.

If your child turns 12 between the first and second doses of the Pfizer vaccine, the CDC is recommending they receive the full regular dose for their second shot. 

Janssen (Johnson & Johnson) COVID-19 vaccine is authorized for adults ages 18 years and older in certain limited situations due to safety considerations. For guidance on respective record review, scheduling and administration of Janssen vaccine see Interim Clinical Considerations for Use of COVID-19 Vaccines: Appendices, References, and Previous Updates | CDC

No, the CDC says people still are considered fully vaccinated starting two weeks after the second dose of the Moderna or Pfizer vaccines, or the single-dose Johnson & Johnson vaccine.

Currently unknown. Some scientists think eventually people may get regular COVID-19 shots like annual flu vaccinations. But researchers will need to study how long protection from the current boosters lasts.

The CDC, and many medical practitioners, are strongly recommending everyone get a flu shot this year. With the flu almost non-existent last year due to the stay-at-home orders, masking and handwashing, many are expecting this flu season to come back strongly. According to the CDC, it is safe to get both your COVID-19 vaccine and the flu vaccine at the same time.

Both are contagious respiratory illnesses, but there are differences. The CDC has detailed information on the differences in signs and symptoms. An easy-to-read graph is also available.

There are many options for showing proof of your COVID-19 vaccination, including carrying your card (or a photocopy of your vaccination card), taking a picture of your card with your phone, or using the MyIRMobile certificate. Learn more about accessing your vaccine records through MyIR. If you need help getting your records, don't have access to the internet, or if you need language assistance, call 800-525-0127, then press #.

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 commercialization of vaccines and treatments, meaning the end of free vaccines and return to market rates, will being in early 2023. We're monitoring the situation and will advise as soon as we know the pricing.

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

There may be requirements for you and your employees to be fully vaccinated. Check with your local government or employer for information.

On October 4, 2021, the Department of Labor (DOL), Health and Human Services (HHS), and the Treasury (collectively, the Departments) issued FAQ guidance to confirm that employers can incentivize employees by offering discounts on monthly insurance premiums for those who have been vaccinated for COVID-19, or impose surcharges for those who choose not to be vaccinated (with some exceptions).

Providing different premium contributions for vaccinated and unvaccinated employees is legally possible through a properly designed health-contingent, activity-based wellness program.

This is an approach that comes with a multitude of regulatory requirements and may carry legal risks. Employers implementing health insurance surcharges must comply with federal anti-discrimination laws and should consider the impact of a surcharge on the health plan's affordability under the Affordable Care Act (ACA).

As a reminder, Premera does not manage employee contributions for group business (beyond the Premera employee health plan), nor do we have the technology in place to do so. Tracking of employee vaccination status and administration of any premium discount or surcharge is the responsibility of the employer.

We can't offer legal advice and recommend any employer looking to impose an incentive or penalty in this manner consult with their own legal counsel.

As a federal contractor, Premera is required to follow the federal mandate for contractors. We will require all employees, including telecommuters, to be fully vaccinated by January 1, 2022. Per the federal mandate, there are no test out options, however, we will be accommodating accepted religious and medical exceptions. We will also be offering an incentive to employees vaccinated by January 1, 2022.

We can't provide you with advice on if you are required to follow either the federal contractor or the 100+ employee federal mandate. We encourage you to check with your own legal counsel on these requirements and set your own standards. 

Premera is not required under either state or federal law to provide coverage for return-to--work testing or occupational testing. Federal and state law do not require that these tests be reimbursed as part of a health plan. If you require return-to-work testing or occupational surveillance testing as part of an accommodation, this is a business decision or it may be required under federal mandate. It is not healthcare treatment or health benefit coverage. Groups need to seek separate legal counsel to determine the best way to pay for these tests other than through the health plan, which could include hiring a company to provide testing that is billed directly to the group.

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. 

For a current list of organizations that can come onsite for vaccines and flu shots, visit B’Link on Premera.com.

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.

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.

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. 

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.

Cost share waivers for telehealth visits ended December 31, 2020.

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.

The new drugs for treating COVID-19 (including Evusheld) are currently covered under our policy as EUA drugs may be accepted per Premera policy 05.01.549: Off-label Use of Drugs and Biologic Agents.
Note: These drugs are covered under mandate and the public health emergency (PHE) and could change.

While Premera may not cover this drug in certain circumstances, it is not restricted at this time when acquired through government distribution systems. When this drug is FDA approved, it's likely that Premera may institute a medical policy with specific criteria on use of this drug. Additionally, coding on administration of these drugs are guided by CMS administration codes.  

Because these drugs are approved only through EUA, our stance on this drug could change based on PHE changes, FDA approval status, or additional data as it becomes available.

Test-to-treat antivirals began distribution by HHS on March 7, 2022. Oral antivirals may only be provided when prescribed by a qualified healthcare provider. Only pharmacies with in-store clinics are eligible for distributing these medications. Get more information and to find a test-to-treat location. 

Cost share waivers for all COVID-19 treatment (both inpatient and outpatient) ended on June 30, 2021.

Treatment costs are still covered as a medical expense. Cost share waivers for COVID-19 diagnostic testing and related provider visit remains in place.

President Joe Biden laid out his strategy to fight the Omicron and Delta coronavirus variants over the winter, which included insurer-funded at-home COVID-19 testing. The rules regarding health plan reimbursement for self-tests purchased by consumers were made available on January 10, 2022. This mandate applies to all commercial plans.

Eligible tests are those with full FDA or EUA authorization and designated as home tests (antigen or molecular approved tests) used for diagnostic purposes (e.g., symptoms or direct exposure). Tests for surveillance purposes such as work or travel continue to be not covered. We will apply the quantity limit of 8 individual tests (not package) per covered member per 30 rolling days. These tests are not available for members with Medicare plans.

You can also order kits directly from the federal government at covidtests.gov (limited to 4 tests per household).

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.

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.

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.

If you require return-to-work testing or occupational surveillance testing as part of an accommodation, this is a business decision or it may be required under federal mandate. It is not healthcare treatment or health benefit coverage. Groups need to seek separate legal counsel to determine the best way to pay for these tests other than through the health plan, which could include hiring a company to provide testing that is billed directly to the group.

Premera is not required under either state or federal law to provide coverage for return-to--work testing, occupational testing, travel or for any other non-diagnostic testing. Federal and state law do not require that these tests be reimbursed as part of a health plan. If you require return-to-work testing or occupational surveillance testing as part of an accommodation, this is a business decision, or it may be required under federal mandate. It is not healthcare treatment or health benefit coverage. Groups need to seek separate legal counsel to determine the best way to pay for these tests other than through the health plan, which could include hiring a company to provide testing that is billed directly to the group.

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.

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.

FDA-authorized COVID-19 Home Test Kits are covered when ordered by a licensed physician or pharmacist, or when purchased by a member for use when a person has COVID-19 symptoms or has had direct exposure. Home test kits will not be covered if used for non-diagnostic purposes (e.g., travel, return to work, etc.).

Members can purchase OTC COVID-19 Home Test Kits from an in-network pharmacy at no direct cost.

Members may submit claims for reimbursement for in-home tests using the OTC claim reimbursement form. A separate claim reimbursement form is required if reimbursement is needed on more than one covered family member. The test you purchase must have been granted full or Emergency Use Authorization (EUA) by the Food & Drug Administration (FDA) and labeled for home use and have been purchased January 15, 2022, or later. Check the EUA list for approved home antigen or molecular approved tests.

View CDC guidance on how to administer and read a COVID-19 self-test.

If you test positive, report your results to the Washington State Department of Health at 800-525-0127.

As a Premera Blue Cross member, you have several ways to get tested for COVID-19 at no out-of-pocket cost. 

Get free, at-home test kits 

• At an in-network pharmacy. Find an in-network pharmacy near you by signing in to your account on premera.com and searching Find a Doctor. You must present your Premera ID card at the pharmacy counter to obtain tests at no cost. 
• In Washington state, online at https://sayyescovidhometest.org/
• Online through ExpressScripts. Set up an account and get a kit shipped to your home. Additionally, Nomi Health is offering FDA-certified, at-home COVID tests for all Premera members. Order your test today
• Medicare members, including those with Medicare Advantage, can get free tests through a Medicare-contracted pharmacy.

For information about how to accurately complete a self-test, visit the Centers for Disease Control and Prevention. 

Get reimbursed
If you do pay for a COVID test, you can get reimbursed for the cost by submitting a claim form. 

• Download and print the claim form 
• Fill out the form 
• Follow the directions and send the completed claim form to the address on the form. 

Additional information on submitting a claim form for reimbursement: 

• You may submit a claim for up to eight individual tests per covered family member every 30 days.  
• Reimbursement is limited to $12 maximum per test (which may include tax, shipping, and handling). 
• Tests must be used by members who have COVID symptoms or who have had direct exposure. They may not be used for the purpose of attending school, work, travel, or events. 
• Tests purchased out-of-pocket at in-network pharmacies and submitted for reimbursement are limited to $12 maximum per test.  
• The test must be approved, or granted Emergency Use Authorization (EUA), by the Food & Drug Administration (FDA). Check the EUA lists for approved Molecular and Antigen home test kits. Search “OTC” to limit results to eligible tests.    
• A member cannot be paid twice for a single test. If you use your FSA/HRA/HSA account debit card to purchase a test, it cannot be submitted to the plan for reimbursement. 

Go to a testing site 
Check out these links to find an in-person testing location near you: 

• Washington state
• All other states

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.

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.

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.

The new drugs for treating COVID-19 (including Evusheld) are currently covered under our policy as EUA drugs may be accepted per Premera policy 05.01.549: Off-label Use of Drugs and Biologic Agents.
Note: These drugs are covered under mandate and the public health emergency (PHE) and could change.

While Premera may not cover this drug in certain circumstances, it is not restricted at this time when acquired through government distribution systems. When this drug is FDA approved, it's likely that Premera may institute a medical policy with specific criteria on use of this drug. Additionally, coding on administration of these drugs are guided by CMS administration codes.  

Because these drugs are approved only through EUA, our stance on this drug could change based on PHE changes, FDA approval status, or additional data as it becomes available.

Test-to-treat antivirals began distribution by HHS on March 7, 2022. Oral antivirals may only be provided when prescribed by a qualified healthcare provider. Only pharmacies with in-store clinics are eligible for distributing these medications. Get more information and to find a test-to-treat location.