To learn about our online enrollment tool with your own personal link, please call Producer Support at 877-205-9725, Option 3.
Preferred Gold 1000
Preferred Silver 3000
Preferred Silver 3000 HSA
Preferred Bronze 5250 HSA
Preferred Bronze 6350
PersonalCare Gold 750
PersonalCare Silver 2500
PersonalCare Bronze 4500
Preferred Gold 1000, Silver 3000, Bronze 6350 (Area 1,5)
Preferred Gold 1000, Silver 3000, Bronze 6350 (Area 2,3)
Preferred Gold 1000, Silver 3000, Bronze 6350 (Area 4)
Preferred Silver 3000, Bronze 5250 HSA (Area 1,5)
Preferred Silver 3000, Bronze 5250 HSA (Area 2,3)
Preferred Silver 3000, Bronze 5250 HSA (Area 4)
PersonalCare Gold 750, Silver 2500, Bronze 4500 (Area 1)
PersonalCare Gold 750, Silver 2500, Bronze 4500 (Area 2)
2016 Enrollment Application (Paper applications cannot be submitted or signed prior to November 1, 2015)
PersonalCare Provider Directory - List of physicians and providers in the PersonalCare Partner Systems Network.
Preferred Silver 3000 CSR1
Preferred Silver 3000 CSR2
Preferred Silver 3000 CSR3
Preferred Silver 3000 HSA CSR1
Preferred Silver 3000 HSA CSR2
Preferred Silver 3000 HSA CSR3
Multi-State Gold 1000
Multi-State Silver 3000
Multi-State Silver 3000 CSR1
Multi-State Silver 3000 CSR 2
Multi-State Silver 3000 CSR 3
Multi-State Silver 3000 HSA
Multi-State Silver 3000 HSA CSR1
Multi-State Silver 3000 HSA CSR2
Multi-State Silver 3000 HSA CSR3
Multi-State Bronze 5250 HSA
Multi-State Bronze 6350
PersonalCare Silver 2500 CSR 1
PersonalCare Silver 2500 CSR 2
PersonalCare Silver 2500 CSR 3
Multi-State Gold 1000, Silver 3000, Bronze 6350 (Areas 1,5)
Multi-State Gold 1000, Silver 3000, Bronze 6350 (Areas 2,3)
Multi-State Gold 1000, Silver 3000, Bronze 6350 (Areas 4)
Multi-State Silver 3000, Bronze 5250 HSA (Areas 1,5)
Multi-State Silver 3000, Bronze 5250 HSA (Areas 2,3)
Multi-State Silver 3000, Bronze 5250 HSA (Areas 4)
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)
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.
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.
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
2015 Enrollment Application
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. On behalf of Premera, Express Scripts is an independent company providing pharmacy benefit services.
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
2016 Individual Supply Order Form
2015 Individual Supply Order Form
Heritage Signature Hospital list 2015
Heritage Signature Hospital list 2014
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!
Check out our member tip sheetfor more information on virtual care.
2016 Individual and Family Application (Paper applications cannot be submitted or signed prior to November 1, 2015)2015 Individual and Family Application One application per family
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:
Your clients can retain their grandfathered plans (established prior to March 23, 2010) or select a new plan during the next open enrollment period.