Genetic Testing for Breast Cancer

Breast cancer will affect around 12 percent of women at some point during their lifetime. This year, actress Angelina Jolie revealed her decision to undergo a double mastectomy after discovering she carried a genetic mutation that greatly increased her risk of breast cancer. We’ve heard some questions about whether genetic testing for the BRCA gene is covered by Premera. Here’s the answer:

Both men and women carry genes known as Breast Cancer Susceptibility genes (BRCA genes). Mutations in these genes are associated with an increased risk of breast and ovarian cancers, but it’s important to keep this risk in perspective. These mutations account for just 5 percent* of all breast cancers.

BRCA genetic testing can identify harmful mutations in these genes. This may help people understand whether they have an increased risk of developing these cancers and allow them to work with their doctor to make informed decisions about the best way to manage their risk.

Medical experts have agreed on a step-by-step process to identify patients who are likely to have these gene mutations. This process is based primarily on family history of breast cancer and other types of cancer, such as ovarian cancer. Premera’s medical policy explains who is eligible for BRCA testing.

All our plans provide coverage for BRCA testing if you meet the criteria set out in the medical policy. Depending on your plan, you may be covered for this testing at 100 percent, which means you would pay no out-of-pocket costs.

Finding the right option for you

If you believe that you may benefit from BRCA testing you should speak to your primary care physician about your personal and family medical history and how this may affect you. If you decide to get tested, here are three steps you can take to ensure you don’t get a surprise bill afterwards:

• Ask your physician to check our medical policy and contact Premera before conducting a BRCA test to make sure you’re covered and understand what out-of-pocket costs you may have to pay.
• Make sure that your doctor is in our network. You can use our “find a doctor” tool to check which doctors in your area are covered by your plan.
• Before you make your appointment, ask your doctor’s office if they charge a “facility fee.” You always pay a share of the cost toward a facility fee, even if your visit is for a preventive service.

If you have questions about BRCA testing, please contact our Customer Service team at the number located on the back of your member ID card.

---

* Statistics on inherited BRCA gene mutations from The Mayo Clinic.

Premera Drug Safety Programs Encourage Communication Between Patients and Physicians

Studies show that consumers see an average of 2.7 different physicians each year. While there are benefits to receiving care from a variety of practitioners to meet your individual healthcare needs, there are also patient safety risks. Omissions in care and dangerous interactions between drugs can lead to medical problems for patients and a subsequent increase in medical costs.  

That’s why Premera has a number of programs in place to help ensure open communications between our members and their physicians as it relates to the prescription medications they are taking. 

RationalMed™ is a program that can help improve the safety of patients’ prescription regimens as they transition among doctors. By integrating medical and pharmaceutical claims, RationalMed™ provides doctors with a complete picture at all of the medications a patient has been recently prescribed by other physicians.

This information helps alert physicians to a patient’s pre-existing medical conditions and also  better equips them to help patients avoid unnecessary medical problems and costs.  Learn more about our RationalMed program.

Steps You Can Take to Avoid the Flu

The flu season has hit early—and hard—this year. You may be worried that you and your family will get the bug when it seems that everyone around you is sick.  But you can do a lot to lessen your chances of infection.

• Get a flu shot. It’s not too late, and it will help. The shot isn’t a guarantee you won’t get the flu, but it can help lessen symptoms if you do. If you’re a Premera member, getting a flu shot is easy and should cost you nothing or very little. Make an appointment with your primary care doctor, or take advantage of Premera’s pharmacy-based immunization program. Simply visit an in-network pharmacy and show the pharmacist your card. Most members will experience little to no out-of-pocket costs when they get their flu shot at an in-network pharmacy; however, your local pharmacist can determine your level of coverage.

• Wash your hands. Frequently, and for at least 20 seconds with soap and hot water. Washing hands is the best method for preventing the spread of disease. Use hand sanitizer, with at least 60% alcohol, only when soap and water are not available.

• Be careful what you touch. Avoid touching your eyes, nose and mouth. Also, be aware of where germs gather: door handles, restaurant menus, ATM buttons, gas pumps, etc. Wash your hands immediately after touching these surfaces, or use a hand sanitizer.

• Wipe down work surfaces. Keyboards, desk phones, and computer mice are among the dirtiest surfaces at work. Take time to clean them on a regular basis with sanitizing wipes or solutions.

Despite your best efforts, you may still end up with the flu. If you are sick, medical experts recommend you stay home at least 24 hours after your fever is gone.

Why Do Healthcare Costs Keep Going Up?

It feels like these days everything just keeps getting more expensive and healthcare is no exception. We’ve all heard that we spend more money than any other nation on medical care.  And we know that for people who buy their own healthcare coverage, costs have increased even more rapidly in recent years. So what exactly is driving these costs?

The biggest driver behind the rates our members pay is the cost of medical care. We spend at least 80 percent of our members’ premium dollar on medical services (85 pecent for large group customers). That means paying for doctors, hospitals, pharmaceuticals, and other forms of medical care.

How we pay for our care

Most doctors are paid on what is known as a “fee for service” model. This means doctors are paid according to the number of patients they see and procedures they perform. A number of healthcare experts believe that this incentivizes some doctors to focus on quantity and high-cost services over quality of care.

Aging and chronic disease

Our population is aging. In 2010, 12.2 percent of Washington’s and 8.1 percent of Alaska’s population was over 65. The Department of Health and Human Services predicts that by 2030, people over 65 will make up over 18 percent of our population in Washington and 14.7 percent in Alaska. Although an aging population leads to higher medical costs, the more pressing concern is the number of us who are suffering from chronic diseases like diabetes and heart disease. The Centers for Disease Control estimates that treating cardiovascular diseases accounts for $1 in every $6 spent on healthcare in this country. Many of these conditions are preventable if people make better diet and lifestyle choices.

Increasing use of technology

Advances in medical technology have increased the quality and length of our lives. However, state-of-the-art technology comes at a price—not only do hospitals and clinics need to pay to purchase this technology (at a price that covers its research and development costs) they also need to pay to train the clinicians and maintain their equipment. Newer technology isn’t always the safest or most effective treatment, but people often think that newer or more expensive treatments are better, which pushes up costs, at times for little or no benefit to the patient.

Choice

Often we find that the more choices we want, the more we have to pay. Healthcare is no different. The fewer restrictions that are placed on care, the more expensive it becomes. Pharmaceutical costs are a great example: Generic drugs are just as safe and effective as their brand name counterparts, yet cost on average 75 percent less. It’s estimated that if generic drug use by Medicaid patients increased by just 5 percent, it could save $3.4 billion per year.

More on healthcare coverage basics:

Understanding How Healthcare Coverage Works

How Do We Set Your Rates?

Understanding How Healthcare Coverage Works

We understand that healthcare coverage can be complicated, and we often get questions from our members about how health plans work. We hope this post will help answer some of those questions.

Members who have questions about their coverage or claims can call Customer Service at the number on the back of their ID card.

Why do my rates change, even when I haven’t used any medical services in the last year?

Healthcare coverage is all about sharing risks and costs. By joining a plan, you become part of a “pool” of people. If you need medical care, the cost of that care is spread across the entire pool of people, who pay for it through their monthly payments.  Most people would be unable to afford a huge hospital bill, but the risk of needing such expensive care is spread across the whole pool, so you can always be confident that Premera will have the funds to meet those needs.

I don’t get sick so why do I need to bother with healthcare coverage?

None of us plan to get sick, but it can be reassuring to know that you have support and coverage if the unexpected happens and you find yourself in an accident or facing a serious illness. Even if you only visit the doctor occasionally, there are still important benefits to having healthcare coverage.

We negotiate with doctors and hospitals on behalf of our customers so that you pay lower rates for care. When you receive care, we send you an “Explanation of Benefits” to show you what the care provider charged, what we paid, and what amount, if any, you may have to pay. It also shows the “provider’s fee adjustment”. This is the discount you receive because Premera has negotiated with the hospital or doctor to reduce what they charge for that service.

Your plan also covers many preventive benefits, like screenings and vaccinations (such as flu shots), without any out-of-pocket costs to you. We want to encourage people to take advantage of these services. Preventing illness keeps our members healthy and keeps costs down for everyone.

Why do I need to use in-network doctors and hospitals?

We have a team of people who are dedicated to negotiating with doctors and hospitals to ensure that our members get safe, effective, and high-value care. Doctors and hospitals who are in our network have agreed to follow our medical policies and have signed up to specific rates for the services they provide. Our medical policies are created by doctors who review guidance from the government, national bodies, medical research organizations, and peer-reviewed medical journals.

If you use a doctor or hospital that is not in our network, there is no limit to the amount that they are able to charge for a service. This means that even when Premera pays them our contracted or “allowed” rate to perform a service or treatment, they still have the option to pursue you for additional fees. This is often known as “balance billing”. Using an in-network doctor or hospital means you will pay lower out-of-pocket costs and reduce your risk of balance billing.

More on healthcare coverage basics:

Why Do Healthcare Costs Keep Going Up?

How Do We Set Your Rates?