To learn about our online enrollment tool with your own personal link, please call Producer Support at 877-205-9725, Option 3.
Premera is offering health plans in 2015 that give your clients a wide range of options and access to an expanded provider network of doctors, hospitals, and pharmacies - statewide, nationwide and beyond.
Preferred Gold 1000/1500
Preferred Silver 2000/3000
Preferred Bronze 5500/6350
Preferred HSA 2500/5250
Gold PPO(Area 1,5)
Gold PPO(Area 2,3)
Gold PPO(Area 4)
Silver PPO(Area 1,5)
Silver PPO(Area 2,3)
Silver PPO(Area 4)
Bronze PPO(Area 1,5)
Bronze PPO(Area 2,3)
Bronze PPO(Area 4)
HSA PPO(Area 1,5)
HSA PPO(Area 2,3)
HSA PPO(Area 4)
Plan Change Form
Individual Supplemental Guide for Non-Grandfathered plans
Preferred Silver CSR1 2000/3000
Preferred Silver CSR2 2000/3000
Preferred Silver CSR3 2000/3000
Preferred Silver CSR1 2500 HSA
Preferred Silver CSR2 2500
Preferred Silver CSR3 2500
Multi-State Gold 1000/1500
Multi-State Silver 2000/3000
Multi-State Bronze 5500/6350
Multi-State HSA Silver 2500/Bronze 5250
Multi-State Silver CSR1 2000/3000
Multi-State Silver CSR 2 2000/3000
Multi-State Silver CSR 3 2000/3000
Multi-State Silver CSR1 2500 HSA
Multi-State Silver CSR2 2500
Multi-State Silver CSR3 2500
Gold Rate Sheet Area 1,5 Inside Exchange
Gold Rate Sheet Area 2,3 Inside Exchange
Gold Rate Sheet Area 4 Inside Exchange
Silver Rate Sheet Area 1,5 Inside Exchange
Silver Rate Sheet Area 2,3 Inside Exchange
Silver Rate Sheet Area 4 Inside Exchange
Bronze Rate Sheet Area 1,5 Inside Exchange
Bronze Rate Sheet Area 2,3 Inside Exchange
Bronze Rate Sheet Area 4 Inside Exchange
HSA Rate Sheet Area 1,5 Inside Exchange
HSA Rate Sheet Area 2,3 Inside Exchange
HSA Rate Sheet Area 4 Inside Exchange
Multi-State Gold 1000/1500, Areas 1,5
Multi-State Gold 1000/1500, Areas 2,3
Multi-State Gold 1000/1500, Area 4
Multi-State Silver 2000/3000 Areas 1,5
Multi-State Silver 2000/3000 Areas 2,3
Multi-State Silver 2000/3000 Area 4
Multi-State Bronze 5500/6350, Areas 1,5
Multi-State Bronze 5500/6350, Areas 2,3
Multi-State Bronze 5500/6350, Area 4
Multi-State HSA 2500/5250 Areas 1,5
Multi-State HSA 2500/5250 Areas 2,3
Multi-State HSA 2500/5250 Area 4
The Premera Adult Health Plan combines dental and vision coverage into one package for consumers age 19 and older. Your clients can enroll on the plan directly with us if they have a Premera metallic plan either in or out of the exchange.
Adult dental coverage without vision benefits is also available to purchase direct from Premera. For family members 19 and over enrolled on metallic plans see our Premera Select Individual Dental Plan. Covered services on this dental plan are provided as outlined on the payment schedule when members see in-network providers.
The Premera Pediatric Dental Plan is available to consumers age 18 or under. For 2015, it's offered as a stand-alone plan and not embedded with the medical plan.
For additional information, contact Producer Support at 1-877-205-9725, Option 3.
Premera Blue Cross has selected Washington National Insurance Company, a company focused on supporting health plans with supplemental health and life insurance that complements your customers’ total health insurance coverage from Premera.
Help your customers gain the additional financial protection with the following products from Washington National:
Since 1911, Washington National has helped Americans protect themselves and their families from the financial hardship that often comes with critical illness, accidents or loss of life. Washington National insures nearly 1 million policyholders and 25,000 employer groups offering important benefits at a competitive price. You can count on Washington National for dependable, high-quality service and support.
To learn more about Washington National and their products please visit: washingtonnational.com. Products are subject to state availability. Contact your Premera producer support representative for more details.
Washington National Insurance Company is an independent provider of supplemental health and life insurance that does not provide Blue Cross Blue Shield products or services. Washington National Insurance Company is solely responsible for its policies. Washington National Insurance Company policies are not considered “qualified health plans” and do not provide essential health coverage as required by the Affordable Care Act. Washington National’s policies are considered “excepted benefits” policies which do not meet the individual mandate requirements of the Affordable Care Act.
Deductible Credit Form
2015 Member Enrollment and Change Application (groups effective in 2014)
2015 Member Enrollment and Change Application Spanish Version (groups effective in 2014)
2015 Member Enrollment and Change Application Guide
HIPAA Pre-existing Change Notice and Instructions
HIPAA Pre-existing Change Notice and Instructions Spanish Version
Other Coverage Questionnaire Enrollment
Request for Certification of Disabled Dependent
Waiver of Coverage
Transition of Care Form
HRA Electronic Funding Authorization
UMB HSA Beneficiary Designation Form
UMB HSA Name Change Request Form
UMB HSA Account Closure/Withdrawal Request
UMB HSA Funds Transfer
HSA Expense Manual Claim Form
Plan Change Form
Declaration of Domestic Partnership Form
AFT Authorization Form for Individual
Individual Adult Health Plan Application
Individual Adult Dental Copay Application
Complete List of Covered Dental Services
HSA Authorization Form form UMB Bank
Tobacco Certification Form - For plans as of 1/1/2014 enrollment dates
Preventive Screening Services - For plans with an effective date on or after Aug. 1, 2012
Application for the Addition of Family Members - For grandfathered plans
Rate Brochure for Individuals and Families - For grandfathered plans
Standard Health Questionnaire - A separate questionnaire must be completed for each family member
Preventive Screening Services - For grandfathered plans
Express Scripts Home Delivery Mail-Order Form - Order prescription drugs through the mail from Express Scripts.
Health, Allergy & Medication Questionnaire - Complete this questionnaire for all new mail prescriptions to help protect yourself against potentially harmful drug interactions and side effects.
Prescription Drug Reimbursement Form - Apply for reimbursement of your prescription costs.
Oral Chemotherapy Reimbursement Form - This form is only to be used for plans that do not have out-of-network prescription coverage.
Authorization for Release of Healthcare Information and Records
Authorization for Release of Psychotherapy Notes
Disclosure Accounting Request
Request for Amendment of Records
Request for Inspection of Records
Affidavit of Domestic Partnership
HSA Authorization From for UMB Bank
Producer of Record Change Form
2015 Individual Supply Order Form
Heritage Signature Hospital list 2015
Heritage Signature Hospital list 2014
Self-Funded Health Plan Authorized Representative Disclosure Form
Student Status Verification
Summary Health Information Authorization for Insured Groups
If your client has a certain life event such as marriage or divorce, birth or adoption of a child, moving to a new area, or losing health coverage, they may qualify to enroll outside the open enrollment period.
As part of the Affordable Care Act of 2010, all health plans must provide a summary of benefits in a standard four-page format. These summaries help people understand how a plan works and makes comparing plans easier.
Teach your clients about our mobile features with our mobile app flyer!
It’s easy. Your client can apply either online or by mail.
Your clients can apply using your own personal enrollment link. Applying online allows you to track your clients current status of their application.
If you do not have a personal enrollment link please call Producer Support at 877-205-9725, Option 3.
If your clients qualify for premium credit assistance, cost share reduction plans or American Indian/Alaska Native plans, they will want to enroll in a plan through Washington Healthplanfinder.
Individuals eligible to apply for a Premera plan must be:
Eligible dependents that can enroll on a plan include:
The open enrollment period this year ended February 15, 2015. But if your client or their family have experienced one of the life events listed below, they may be able to apply for coverage now, in a special enrollment period.
Your Sales Executive and Producer Support are available to help answer any questions you might have about these plans.
Your clients can retain their grandfathered plans (established prior to March 23, 2010) or select a new plan during the next open enrollment period starting November 1, 2015.