MatchmakerTM for Behavioral Health
Behavioral health is a key part of whole person care. Premera has a navigation service to help members find the care they need, and to assist providers find care for their patients. With one phone call to our HMO Plus Team number (844-PBC-HMO1 or 844-722-4661), Premera can help a member find a provider that meets their needs and is accepting patients.
Urgent and emergency care
Our HMO is an in-network offering only. However, when an urgent situation arises an HMO member can utilize urgent care and emergency care anywhere in the United States. Emergency care is explained as the following:
- “Examination and treatment as required to stabilize a patient to the extent the examination and treatment are within the capability of the staff and facilities available at a hospital.
- "Stabilize means to provide medical, mental health, or substance
use disorder treatment necessary to ensure that, within reasonable medical probability, no material deterioration of an emergency condition is likely to occur during or to result from the transfer of the patient from a facility; and for a pregnant
member in active labor, to perform the delivery.”
Urgent care comes to the member with Dispatch Health
Members can avoid wait times for urgent care with Dispatch Health, a provider group contracted with Premera.
- At the cost of their urgent care copay, members can
request Dispatch Health come to their home or work.
- They provide on-demand, qualified, acute care to keep patients out of the hospital seven days per week, 8 a.m. to 10 p.m. Pacific Time.
- A provider, case manager or patient can request on behalf of the member via phone (855) 354-8961
- Once on the scene the care team can provide 60-70% of care available in the ER
- Dispatch Health collaborates closely with the patient’s primary care provider for close follow up if needed.
24/7 Virtual care
Premera believes in helping members at all points of their care journey. There are partnerships in place with many best-in-class organizations to help members live healthier lives. HMO members have access to virtual care
providers 24/7 through the Premera MyCare app. Virtual care providers are as follows:
- 24-Hour NurseLine
- Doctor On Demand
- Boulder Care
- Livongo (for SEBB only)
Enhanced digital experience
To give HMO members more control over the management of their healthcare, the HMO program provides digital tools like:
- PCP Selection
- Referral and authorization notifications
- Virtual visits
HMO pharmacy services include dedicated support from the HMO Plus Team and proactive outreach focusing on providing the right care at the right time. Premera pharmacists are available for clinical consultations with members and providers to answer any
medication questions they may have, which may include:
- Reviewing medications and providing education or answering
drug information questions
- Discussing medication side effects, interactions, and
- Reviewing benefit information and identifying savings
- Helping support medication management addressing barriers
to optimal use
HMO members have access to the National 2.0
network through Express Scripts (ESI), providing many options for patients to
fulfill their medication needs. Most Premera HMO plans (SEBB not included) will require the use of exclusive home
delivery using the Express Scripts mail-order pharmacy for maintenance
medications it’s designed to be a cost saving strategy for members. For more information: https://www.premera.com/wa/provider/pharmacy/understanding-your-benefits/about-pharmacy/
- The HMO
formulary is organized into 4-tiers that drive the members cost share:
preferred generics (tier 1), preferred brand (tier 2), preferred specialty
(tier 3), and non-preferred drugs (tier 4). In addition, some drugs may
also be excluded from coverage. The full drug list can be found here.
- All drugs
are reviewed and placed into a formulary tier by the Premera Pharmacy &
Therapeutics (P&T) Committee based on clinical efficacy, safety,
alternatives, and cost effectiveness.
- The Premera
P&T Committee is an independent
set of experts composed of leading physicians, pharmacists, health economists,
a bioethicist, and a member representative.
HMO plans cover certain medical services that are provided by a dental provider, which are listed as covered under the medical plan, but dental services are offered separately from HMO.
Beginning January 1, 2023, with the HMO medical product, an employer can select a Premera branded dental plan. If the employer selects a dental plan, their employees will have dental coverage. If an employer doesn’t select a Premera Blue Cross dental plan,
then the member will not have dental coverage through Premera.
Digital care management (powered by Well frame)
Our digital care management service meets members where they are in the mode and cadence they prefer. The service offering digital text and chat functionality between a member and their care manager. It also provides:
- Digital programs curated for a digital user with case management support
- Care transition management
- Behavioral health coordination
- Condition management
- Lifestyle management
To refer a member to Premera’s case and digital management service: