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 June 21, 2022

    • See COVID-19 Key Dates section for new ABA end date.
    • Members can purchase over-the-counter COVID-19 home test kits from an in-network pharmacy at no direct cost or online through either Express Scripts or Nomi Health. See COVID-19 benefits and testing section for details.
    • The federal Public Health Emergency was extended another 90 days to July 15, 2022. See the COVID-19 key dates grid for details.
      A second 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 to 4 years and a Moderna vaccine was authorized for children 6 months to 5 years.

    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) July 15, 2022*
    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 July 15, 2022.*
    Applied behavioral analysis (ABA) available through telehealth (Premera initiative) December 31, 2022
    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) July 15, 2022*

     

    COVID-19 vaccines

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

  • The Centers for Disease Control and Prevention (CDC) recommends a booster vaccine from Pfizer/BioNTech for ages 5 and up or a Moderna booster for ages 6 and up at least 4 to 6 months after receiving the second dose. Johnson & Johnson booster vaccines are available for those 18 and over at least 2 months after receiving the first dose.

     

    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.

    The dose of the Pfizer COVID-19 for children ages 5-11 is a smaller dose than the dose for people age 12 and up. 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. 

     

     

    The CDC has recommended that people that received the single dose Johnson & Johnson vaccine receive a booster dose. Anyone who got a J&J shot at least two months ago is eligible, regardless of age or other factors.

    The CDC's recommendations now allow for "mix and match" dosing for booster shots depending on personal preference. Eligible individuals may choose which vaccine they receive as a booster dose. For people who originally got a J&J vaccination, the Moderna and Pfizer shots appeared to offer a stronger boost. But researchers cautioned the study was too small to say one combination is better than another.

    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 #.

    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.

    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.

    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. 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

    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.

    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.

  • Virtual care benefits

  • 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.

    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.

    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.

  • COVID-19 benefits and testing

  • 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 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.



    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.

    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.

    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.

     

    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.

    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. 
    • Online at covidtests.gov. Limit one order per household.  
    • 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 the federal government at covidtests.gov or 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: 

     

     

     

    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.

    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.

    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.

    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.

    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