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)
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)
Please call us for more information 800-722-1471.
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
For 2016 the Individual Select Dental Plan is available as a stand-alone plan for family members 19 and over.
Individual Select Dental Plan for Adults flyer
Individual Select Dental Plan for Adults application
In 2015 the Individual Select Dental plan provides adult dental coverage for family members 19 and over that are enrolled on metallic plans. Covered services on this dental plan are provided as outlined on the payment schedule when members see in-network providers.
Covered services and copay schedule
The Premera Pediatric Dental Plan is available to consumers age 18 or under. During the annual open enrollment period your clients can purchase this coverage as a stand-alone plan. Outside of the open enrollment period this plan can only be purchased when your clients are enrolling on a metallic plan.
2016 Individual Pediatric Dental Plan flyer
2016 Individual Pediatric Dental Plan application
2015 Individual Pediatric Dental Plan flyer
2015 Individual Pediatric Dental Plan application
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
HSA Authorization Form for UMB Bank
Declaration of Domestic Partnership Form
AFT Authorization Form for Individual
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. Express Scripts Home Delivery is an independent company that provides mail-order pharmacy services on behalf of Premera Blue Cross.
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
Producer of Record Change Form
2016 Individual Supply Order Form
2015 Individual Supply Order Form
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.
Heritage Signature hospital list 2016
Heritage Signature hospital list 2015
Teach your clients about our mobile features with our mobile app flyer!
Check out our member tip sheet for more information on virtual care.
Provide five pieces of proof of residence, which means:
A valid Washington driver's license, state-issued identification card, tribal or military identification that includes the applicant's photograph and residential address.
Plus any four of the following documents:
A complete copy of each document must be submitted. All documents must show the applicant's full name and current residential address. A post office or mail delivery address is not acceptable.
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.
Clients who do not qualify for assistance can also apply for coverage through Washington Healthplanfinder.
Individuals eligible to apply for a Premera plan if they are:
Eligible dependents that can enroll on a plan include:
Open enrollment for 2016 runs November 1-2015 through January 31, 2016.
If your client has experienced a qualifying event outside the open enrollment period, they must be eligible to apply for coverage in a special enrollment period.