Medical Policy and Coding Updates

Effective August 7, 2026

Denosumab Products, 5.01.658  PBC | Premera HMO
Medical necessity criteria updated

• Bildyos (denosumab-nxxp), Enoby (denosumab-qbde), Bilprevda (denosumab-nxxp) and Xtrenbo (denosumab-qbde) now listed as preferred denosumab products.
• Boncresa, Bosaya, Conexxence, Jubbonti, Ospomyv, Osvyrti, Prolia, and Stoboclo now listed as non‑preferred products, and to require an inadequate response or intolerance to both Bildyos (denosumab‑nxxp) and Enoby (denosumab‑qbde).
• Aukelso, Bomyntra, Jubereq, Osenvelt, Oziltus, Wyost, Xbryk, and Xgeva now listed as non‑preferred products, and to require an inadequate response or intolerance to both Bilprevda (denosumab‑nxxp) and Xtrenbo (denosumab‑qbde).
• Criteria for prevention of skeletal‑related events in multiple myeloma and bone metastases from solid tumors to include a dose limit of 120 mg every 4 weeks.

Mobile Cardiac Outpatient Telemetry and Implantable Loop Recorders, 2.02.510  PBC | Premera HMO
Medical necessity criteria updated

• Now includes a requirement for implantable loop recorders (ILRs) that individuals must undergo monitoring for more than 14 consecutive days.
• Individuals may be eligible for ILRs when undergoing evaluation for suspected atrial fibrillation (AF) as a cause of cryptogenic stroke who have had a negative standard AF workup.

Effective July 2, 2026

Drugs for Rare Diseases, 5.01.576  PBC | Premera HMO
Medical necessity criteria added

• Givlaari (givosiran) is subject to review for site of service administration.

Immune Checkpoint Inhibitors, 5.01.591  PBC | Premera HMO
Medical necessity criteria updated

• Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) SC is subject to review for site of service administration.

Immune Globulin Therapy, 8.01.503  PBC | Premera HMO
Medical necessity criteria added

• Yimmugo (immune globulin intravenous, human-dira) is subject to review for site of service administration.

Medical necessity criteria updated

• Guillain-Barre syndrome treatment criteria now require severe disease with significant weakness and initiation of treatment within 4 weeks of symptom onset.
• Multifocal motor neuropathy criteria now require stepwise or slowly progressive asymmetric limb weakness for at least 1 month, motor involvement of at least 2 nerves on nerve conduction studies, and normal sensory nerve conduction studies except for minor vibration loss in the lower limbs.
• Neuromyelitis optica spectrum disorder criteria now allow diagnosis confirmation based on a single clinical characteristic.
• Antiphospholipid syndrome criteria now allow catastrophic antiphospholipid syndrome when plasma exchange is not an option and intravenous immunoglobulin is not used as chronic or prophylactic therapy.

Pharmacologic Treatment of High Cholesterol, 5.01.558  PBC | Premera HMO
Medical necessity criteria added

• Leqvio (inclisiran) is subject to review for site of service administration.

Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis, 5.01.593  PBC | Premera HMO
Medical necessity criteria added

• Amvuttra (vutrisiran) and Onpattro (patisiran) are subject to review for site of service administration.

Pharmacotherapy of Miscellaneous Autoimmune Diseases, 5.01.564  PBC | Premera HMO
Medical necessity criteria added

• Rystiggo (rozanolixizumab-noli) is subject to review for site of service administration.

Medical necessity criteria updated

• Voyxact criteria revised to lower urine protein-to-creatinine ratio (UPCR) thresholds, add an estimated Glomerular Filtration Rate greater than or equal to 30 mL/min/1.73 m² requirement, exclude individuals on dialysis or post‑transplant, and require prior inadequate response or intolerance to Filspari or Tarpeyo.

Prostate Artery Embolization, 7.01.55  PBC | Premera HMO
New policy

• Prostate artery embolization is considered investigational as a treatment for benign prostatic hyperplasia.

Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533  PBC | Premera HMO
Medical necessity criteria updated

• Poland syndrome added to the list of breast conditions for which reconstructive breast surgery may be considered medically necessary when criteria are met.

Site of Service: Infusion Drugs and Biologic Agents, 11.01.523  PBC | Premera HMO
New policy

• Amvuttra (vutrisiran), Onpattro (patisiran), Yimmugo (immune globulin), Givlaari (givosiran), Keytruda Qlex (pembrolizumab and berahyaluronidase alfa‑pmph), Leqvio (inclisiran), and Rystiggo (rozanolixizumab‑noli) are subject to review for site of service administration.

Effective July 1, 2026

Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  PBC | Premera HMO
Title change

• Updated from Site of Service Ambulatory Service Center Select Surgical Procedures to Site of Service Ambulatory Service Center Select Surgical or Diagnostic Procedures in Adults.

Medical necessity criteria added

• Upper Gastrointestinal Endoscopy is subject to review for site of service.

Upper Gastrointestinal (UGI) Endoscopy in Adults, 2.01.533  PBC | Premera HMO
Title change

• Updated from Upper Gastrointestinal (UGI) Endoscopy for Adults to Upper Gastrointestinal (UGI) Endoscopy in Adults.

Medical necessity criteria added

• UGI endoscopy is subject to review for site of service.

Effective June 5, 2026

Carpal Tunnel Release Surgical Treatments, 7.01.595  PBC | Premera HMO
Site of Service Ambulatory Service Center (ASC): Select Surgical or Diagnostic Procedures in Adults, 11.01.525  PBC | Premera HMO
Medical necessity criteria updated

• Carpal tunnel release surgical treatments are subject to review for site of service.

Intracoronary Drug Delivery Balloon Procedures, 7.01.97  PBC | Premera HMO
New policy

• The use of percutaneous coronary intervention with a drug-coated balloon for the treatment of intracoronary in-stent restenosis is considered investigational.

Effective for dates of service on and after June 5, 2026, the following updates will apply to the Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines for Radiation Therapy. As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Radiation Therapy Program Expansion

Addition of Electronic Brachytherapy – Skin and Orthovoltage

• Clinical indications:
  • Treatment of non‑melanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma.
  • Use in select non‑malignant conditions.

For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines.

New medical policies
Effective May 1, 2026

Hematopoietic Cell Transplantation for Acute Myeloid Leukemia, 8.01.542  PBC | Premera HMO
New policy

• This policy replaces Hematopoietic Cell Transplantation for Acute Myeloid Leukemia, 8.01.26, which is now deleted.
• Second hematopoietic cell transplantation (HCT) for relapsed acute myeloid leukemia after initial HCT may be considered medically necessary when criteria are met.

Prescription Digital Health Diagnostic Aid for Autism Spectrum Disorder, 3.03.523  PBC | Premera HMO
New policy

• This policy replaces Prescription Digital Health Diagnostic Aid for Autism Spectrum Disorder, 3.03.01, which is now deleted.
• Prescription digital health technologies as a diagnostic aid for autism spectrum disorder are considered investigational.

Revised medical policies
Effective May 1, 2026

Balloon Dilation of the Eustachian Tube, 7.01.606  PBC | Premera HMO
Medical necessity criteria updated

• Criteria updated to lower the age requirement from 22 years to 8 years for the Acclarent AERA Eustachian Tube Balloon Dilation System and to reduce the required symptom duration from 12 months to 3 months.
• Language added to specify use with a device cleared by the United States Food and Drug Administration (FDA) and used according to FDA labeling.

Medical necessity criteria added

• A list of conditions for which treatment using balloon dilation of the eustachian tube is considered not medically necessary was added.
• Balloon dilation of the eustachian tube in individuals less than 8 years of age is considered investigational.

Sinus Surgery in Adults, 7.01.559  PBC | Premera HMO
Medical necessity criteria updated

• Expanded the list of diagnoses considered medically necessary for functional endoscopic sinus surgery to include abscesses related to sinusitis, symptomatic concha bullosa, and sinonasal tumors.

New pharmacy policies
Effective May 1, 2026

Dry Eye Disease Medications, 5.01.661  PBC | Premera HMO
New policy

• Drugs for dry eye treatment removed from Medical Necessity Criteria for Pharmacy Edits, 5.01.605 and incorporated into this policy with no changes to criteria.

Revised pharmacy policies
Effective May 1, 2026

Bispecific Antibodies, 5.01.650  PBC | Premera HMO
Medical necessity criteria updated

• Rybrevant Faspro (amivantamab and hyaluronidase-lpuj) criteria revised to include a maintenance dose limit when used as monotherapy or in combination with Lazcluze, specifying a maximum dose of 4,640 mg every 4 weeks.
• Tecvayli criteria to clarify monotherapy use in individuals with at least 4 prior lines of therapy and to add a new combination indication with daratumumab hyaluronidase‑fihj for relapsed or refractory multiple myeloma after at least 1 prior line of therapy.

BRAF and MEK Inhibitors, 5.01.589  PBC | Premera HMO
Medical necessity criteria added/updated

• Braftovi (encorafenib) criteria for metastatic colorectal cancer revised to replace use in combination with Erbitux and mFOLFOX6 with use in combination with Erbitux and fluorouracil‑based chemotherapy.

Length of approval criteria updated

• Initial authorization for oral drugs listed in the policy increased from 3 months to 6 months.

Chronic Hepatitis B Antiviral Therapy, 5.01.636  PBC | Premera HMO
Medical necessity criteria removed

• Epivir-HBV (lamivudine) no longer included in policy as the product has been discontinued.

Medical necessity criteria updated

• Pegasys (peginterferon alfa-2a) criteria revised to include indications for the treatment of:
  • Hepatitis D virus.
  • Polycythemia vera.
  • First- or second-line treatment of essential thrombocytopenia.
• Pegasys (peginterferon alfa-2a) for treatment of myelofibrosis criteria to clarify use in individuals with a JAK2 V617F mutation.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

Epidermal Growth Factor Receptor (EGFR) Inhibitors, 5.01.603  PBC | Premera HMO
Medical necessity criteria updated

• Erbitux (cetuximab) for treatment of metastatic colorectal cancer criteria revised to replace use in combination with Braftovi and mFOLFOX6 with use in combination with Braftovi and fluorouracil‑based chemotherapy.

Length of approval criteria updated

• Initial authorization for oral drugs listed in the policy increased from 3 months to 6 months.

Erythroid Maturation Agents, 5.01.614  PBC | Premera HMO
Medical necessity criteria updated

• Reblozyl (luspatercept-aamt) for treatment of beta thalassemia criteria to require that it will not be used in combination with Aqvesme (mitapivat).
• Reblozyl criteria for the treatment of anemia in individuals without prior erythropoiesis‑stimulating agent use revised to clarify individual may require regular red blood cell (RBC) transfusions for symptomatic anemia and remove the requirement for receipt of a minimum of 2 red blood cell units within the past 8 weeks.

Length of approval criteria updated

• Initial authorization for Reblozyl (luspatercept-aamt) increased from 6 months to 12 months.
• Non-formulary exception review no longer included in authorization criteria.

Folate Antimetabolites, 5.01.617 PBC | Premera HMO
Medical necessity criteria updated

• Axtle (pemetrexed), brand pemetrexed (Avyxa‑unbranded), brand pemetrexed (Hospira‑unbranded), and brand pemetrexed (Novaplus‑unbranded) criteria revised for the treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) after four cycles of platinum‑based chemotherapy to clarify use in non‑squamous disease.
• Brand pemetrexed (Accord-unbranded), pemetrexed (BluePoint Laboratories-unbranded), pemetrexed (Sandoz-unbranded), pemetrexed (Teva-unbranded) when used in combination with pembrolizumab and platinum chemotherapy revised to clarify treatment of NSCLC is for non-squamous.
• Axtle (pemetrexed), brand pemetrexed (Avyxa-unbranded), brand pemetrexed (Hospira-unbranded), brand pemetrexed (Novaplus-unbranded), brand pemetrexed (BluePoint Laboratories-unbranded), brand pemetrexed (Sandoz-unbranded), brand pemetrexed (Teva-unbranded) criteria revised to include indication for initial chemotherapy treatment, in combination with cisplatin, for individuals with malignant pleural mesothelioma whose disease is unresectable or who are otherwise not candidates for curative surgery.

Medical necessity criteria added

• Generic pralatrexate may be considered medically necessary for the treatment of relapsed or refractory peripheral T-cell lymphoma.

Medical necessity criteria removed

• Brand pemetrexed ditromethamine is no longer included in the policy as product has been discontinued.

Length of approval criteria updated

• Initial authorization for Xatmep (methotrexate) for treatment of polyarticular juvenile idiopathic arthritis, and Rasuvo (methotrexate) increased from 6 months to 12 months.
• Updated initial authorization for all oral drugs listed in the policy from 3 months to 6 months.

HER2 Inhibitors, 5.01.514  PBC | Premera HMO
Medical necessity criteria updated

• Hernexeos (zongertinib) criteria no longer require that the individual has received prior systemic therapy, including platinum-based chemotherapy.
• Hyrnuo (sevabertinib) criteria to require that it is administered as monotherapy.

Length of approval criteria updated

• Initial authorization for oral drugs listed in the policy increased from 3 months to 6 months.

Management of Opioid Therapy, 5.01.529  PBC | Premera HMO
Medical necessity criteria updated

• Long‑acting opioid therapy quantity limit criteria for chronic pain revised to expand the specialist requirement to include individuals seen by a provider who is supervised by, or regularly consults with, a board‑certified specialist as defined by the American Board of Medical Specialties (ABMS).
• Long‑acting opioid therapy quantity limit criteria for opioid use disorder to clarify that specialty care may be provided by an addiction specialist or by a provider who is supervised by, or regularly consults with, a board‑certified addiction specialist as defined by the ABMS, and to replace the pain management contract requirement with a management contract.

Medical necessity criteria added

• Long-acting opioid quantity limit table revised to include tapentadol HCL ER.

Medical necessity criteria removed

• Bunavail (buprenorphine/naloxone) and Morphabond ER (morphine sulfate ER) no longer included in policy criteria as products have been discontinued.

Migraine and Cluster Headache Medications, 5.01.503  PBC | Premera HMO
Medical necessity criteria removed

• Amerge (naratriptan) no longer included in policy criteria as it was removed from the market.

Medical necessity criteria updated

• Symbravo (rizatriptan/meloxicam) criteria revised to eliminate requirement for a trial of generic rizatriptan in combination with 2 generic NSAIDs and absence of medication overuse headaches, and to require trial of two generic triptan agents.
• Generic sumatriptan/naproxen and Treximet revised to eliminate the requirement for a trial of generic sumatriptan in combination with 2 NSAIDs and absence of medication overuse headaches, and to require trial of two generic triptan agents.
• Elyxyb (celecoxib oral solution) criteria revised to specify that required triptan trials consist of 2 different generic triptan medications, and to remove the requirement that individuals not experience medication overuse headaches.
• Atzumi (dihydroergotamine), Brekiya (dihydroergotamine), and Trudhesa (dihydroergotamine) removed requirement that individual is not experiencing medication overuse headaches.
• Generic dihydroergotamine nasal spray and Migranal (dihydroergotamine) criteria revised to include an age requirement of 18 years or older, require trial of at least 2 different generic triptan medications - one with a non‑oral route of administration, with inadequate response or intolerance - and removed the requirement related to medication overuse headaches.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

Medical Necessity Criteria for Pharmacy Edits, 5.01.605  PBC | Premera HMO
Medical necessity criteria removed

• Drugs for dry eye treatment moved from this policy to Dry Eye Disease Medications, 5.01.661 with no changes to criteria.
• Adoxa, Aktipak, Avage, Benzamycinpak, Dermasorb TA, Dxevo, Entocort EC, First-Hydrocortisone, Minocin, Monodox, Pazeo, Pediaderm HC, Pediaderm TA, Psorcon, Rosanil, Selrx, Striant, Tarka, Tersi, Tretin-X, and Twynsta no longer included in the policy as the products have been discontinued.
• Aveeno, Cortizone, and Noble Formula HC no longer listed as brand topical corticosteroids.
• Patanase no longer listed as an intranasal brand antihistamine product.
• Betoptic S, Istalol, Timoptic, and Timoptic-XE no longer listed as a brand ophthalmic beta blocker.
• Doxycycline IR-DR, Omeclamox-Pak, and Talicia no longer listed as brand oral antibiotics and their generics.
• Arthrotec no longer listed as a brand oral NSAID.
• Avar-E, Avar-E LS, Clindamycin/Benzoyl Peroxide, Clindamycin Phosphate, and Epiduo no longer listed as brand topical acne or rosacea products.

Medical necessity criteria updated

• Arynta (lisdexamfetamine dimesylate) criteria now include a quantity limit of 70 mg (7 mL) per day.
• Eurax (crotamiton) criteria to require use of generic Crotan (crotamiton) or generic Pruradik (crotamiton) first.
• Linzess (linaclotide) criteria now includes a quantity limit of 1 capsule per day.
• Brinsupri (brensocatib) criteria for pediatric individuals aged 12 to 17 to require 1 or more pulmonary exacerbations in the prior 12 months.
• Samsca (tolvaptan) and Jynarque (tolvaptan) criteria to require the individual has tried and had an inadequate response or intolerance to generic tolvaptan.
• Pruradik (crotamiton) criteria no longer includes requirement to use generic Crotan (crotamiton) first.
• Initial authorization duration for Austedo, Austedo XR, Ingrezza, Korsuva, Prialt, and Visudyne is now 12 months.

Medical necessity criteria added

• Arbli (losartan oral suspension) may be considered medically necessary as an angiotensin II receptor blocker when criteria are met.
• Crotan (crotamiton) may be considered medically necessary for the treatment of scabies when criteria are met.
• Cardamyst (etripamil) may be considered medically necessary for the conversion of acute symptomatic episodes of paroxysmal supraventricular tachycardia to sinus rhythm when criteria are met.
• Javadin (clonidine oral solution) may be considered medically necessary for the treatment of hypertension when criteria are met.
• Samsca, Jynarque, and generic tolvaptan now include a quantity limit of 2 tablets per day.
• Yuvezzi (carbachol and brimonidine) may be considered medically necessary for the treatment of presbyopia in adults when criteria are met.
• Zybic (meloxicam) may be considered medically necessary as a brand oral nonsteroidal anti-inflammatory drugs (NSAID) when criteria are met.

Miscellaneous Oncology Drugs, 5.01.540  PBC | Premera HMO
Medical necessity criteria added

• Ibrance (palbociclib) may be considered medically necessary for the treatment of adult individuals with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer when criteria are met.
• Generic lomustine may be considered medically necessary for the treatment of primary and metastatic brain tumors or Hodgkin's lymphoma when criteria are met.

Medical necessity criteria updated

• Beizray (docetaxel) and Docivyx (docetaxel) to include a new indication in combination with carboplatin and trastuzumab, with or without pertuzumab, as neoadjuvant or adjuvant therapy for previously untreated, recurrent, or metastatic HER2‑positive breast cancer.
• Blenrep (belantamab) criteria to require use in combination with bortezomib and dexamethasone clarifying it is for the first 8 cycles, then continued as monotherapy.
• Darzalex (daratumumab) to include a new indication for multiple myeloma in combination with Kyprolis (carfilzomib), lenalidomide, and dexamethasone as first-line treatment.
• Darzalex Faspro to include a new indication in combination with Tecvayli (teclistamab-cqyv) in individuals with relapsed or refractory multiple myeloma who have received at least 1 prior line of therapy including a proteasome inhibitor and an immunomodulatory agent.
• Kyprolis (carfilzomib) to include a new indication as first line treatment for multiple myeloma when used in combination with daratumumab, lenalidomide, and dexamethasone.

Length of approval criteria updated

• Initial authorization for oral drugs listed in the policy increased from 3 months to 6 months.

mTOR Kinase Inhibitors, 5.01.533  PBC | Premera HMO
Medical necessity criteria updated

• Generic everolimus tablets and Afinitor (everolimus) to include new indication for the treatment of metastatic endometrial carcinoma when criteria are met.

Length of approval criteria updated

• Initial authorization for all drugs listed in the policy increased from 3 months to 6 months.

Omisirge (Omidubicel), 5.01.638  PBC | Premera HMO
Medical necessity criteria updated

• Omisirge (omidubicel-onlv) for treatment of hematologic malignancies criteria revised to remove the requirement that the individual have no prior allogenic hematopoietic stem cell transplant.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

Pharmacologic Treatment of Interstitial Lung Disease, 5.01.555  PBC | Premera HMO
Medical necessity criteria updated

• Esbriet, brand pirfenidone, generic pirfenidone, and Ofev criteria for the treatment of idiopathic pulmonary fibrosis (IPF) now requires high-resolution computed tomography (HRCT) to be performed in the past 24 months; and aligns the diagnostic criteria with the 2018 American Thoracic Society (ATS) / European Respiratory Society (ERS) / Japanese Respiratory Society (JRS) / Latin American Thoracic Association (ALAT) diagnosis for IPF.
• Jascayd criteria for the treatment of IPF now require trial of pirfenidone and Ofev first unless contraindicated; specifies a 36 mg per day dose when used in combination with pirfenidone; requires HRCT to be performed in the past 24 months; and aligns the diagnostic criteria with the 2018 ATS/ERS/JRS/ALAT criteria for IPF.
• Ofev criteria includes a change of the description from chronic fibrosing interstitial lung diseases with a progressive phenotype to progressive pulmonary fibrosis (PPF).
• Ofev criteria for PPF to require the disease progressed within the last 12 months as documented by the presence of at least 2 of the 3 following domains: worsening respiratory symptoms, physiological progression, and radiologic progression demonstrated on HRCT, and to restrict use in combination with pirfenidone.

Medical necessity criteria added

• Added quantity limits to Esbriet, brand pirfenidone, generic pirfenidone, Jascayd, Ofev, Tyvaso, Tyvaso DPI, and Yutrepia.
• Esbriet (pirfenidone), brand pirfenidone, and generic pirfenidone may be considered medically necessary for the treatment of PPF when criteria are met.
• Jascayd (nerandomilast) may be considered medically necessary for the treatment of PPF when criteria are met.

Length of approval criteria updated

• Updated the initial authorization duration from 6 months to 12 months for Tyvaso, Tyvaso DPI, and Yutrepia.

Pharmacologic Treatment of Sleep Disorders, 5.01.599  PBC | Premera HMO
Medical necessity criteria added

• Generic sodium oxybate may be considered medically necessary for the treatment of cataplexy in narcolepsy, and excessive daytime sleepiness in narcolepsy when criteria are met.

Medical necessity criteria updated

• Lumryz (sodium oxybate), brand and generic sodium oxybate, Xyrem (sodium oxybate), Sunosi (solriamfetol), Wakix (pitolisant), and Xywav (calcium, magnesium, potassium, and sodium oxybates) criteria for diagnosis of narcolepsy revised to clarify that the sleep study must be an in-laboratory sleep study.
• Wakix (pitolisant) for treatment of cataplexy criteria revised to lower the age requirement from 18 years or older to 6 year or older.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

Pharmacotherapy of Type 1 and Type 2 Diabetes Mellitus, 5.01.569  PBC | Premera HMO
Medical necessity criteria updated

• All criteria in policy revised to include an age requirement.

Medical necessity criteria added

• Sitagliptin-metformin XR may be considered medically necessary for the treatment of adults with type 2 diabetes mellitus when criteria are met.

Medical necessity criteria removed

• Onglyza (saxagliptin) and Kombiglyze XR (saxagliptin and metformin) no longer included in policy as these drugs have been removed from the market.

Length of approval criteria updated

• Non-formulary exception review no longer included in authorization criteria.

Use of Vascular Endothelial Growth Factor Receptor (VEGF) Inhibitors and Other Angiogenesis Inhibitors in Oncology Treatment, 5.01.517  PBC | Premera HMO
Medical necessity criteria added

• Generic pomalidomide may be considered medically necessary when criteria are met:
  • In combination with dexamethasone for the treatment of multiple myeloma.
  • In combination with Darzalex Faspro (daratumumab and hyaluronidase‑fihj) and dexamethasone for the treatment of multiple myeloma.
  • For the treatment of Kaposi sarcoma in adult individuals.

Medical necessity criteria updated

• Pomalyst (pomalidomide) criteria to require an inadequate response or intolerance to generic pomalidomide.

Length of approval criteria updated

• Initial authorization for oral drugs listed in the policy increased from 3 months to 6 months.

Xolair (omalizumab), 5.01.513  PBC | Premera HMO
Medical necessity criteria updated

• Exdensur may not to be used concurrently with Xolair (omalizumab) when the medications are being used to treat asthma.
• Chronic idiopathic urticaria dose limit increased from 300 mg every 4 weeks, to 600 mg every 2 weeks.

Length of approval criteria updated

• Initial authorization for all reviews increased from 6 months to 12 months.
• Non-formulary exception review no longer included in authorization criteria.

No updates this month.

Effective May 1, 2026

Hematopoietic Cell Transplantation for Acute Myeloid Leukemia, 8.01.26

• This policy is replaced with Hematopoietic Cell Transplantation for Acute Myeloid Leukemia, 8.01.542.

Prescription Digital Health Diagnostic Aid for Autism Spectrum Disorder, 3.03.01

• This policy is replaced with Prescription Digital Health Diagnostic Aid for Autism Spectrum Disorder, 3.03.523.

Added codes
Effective September 4, 2026

Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence, 1.01.17  PBC | Premera HMO
Now considered investigational.

E0740

Effective July 2, 2026

Prostate Artery Embolization, 7.01.55  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

37243

Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non-Orthopedic Conditions, 2.01.543  PBC | Premera HMO
Now considered investigational.

G0465

Reconstructive Breast Surgery/Management of Breast Implants, 7.01.533 PBC | Premera HMO
Now requires review for cosmetic and prior authorization.

15769

Now requires review for cosmetic.

C1789

Effective June 5, 2026

Carelon Medical Benefits Management Radiation Oncology
Now reviewed by Carelon for medical necessity and prior authorization.

70472

Intracoronary Drug Delivery Balloon Procedures, 7.01.97  PBC | Premera HMO
Now considered investigational.

0913T, 0914T, C9610

Effective May 1, 2026

Hematopoietic Cell Transplantation for Acute Myeloid Leukemia, 8.01.26  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

38230, 38232, 38240, 38241, S2142, S2150

Revised codes
Effective July 1, 2026

Site of Service Ambulatory Service Center (ASC): Select Surgical Procedures for Adults, 11.01.525  PBC | Premera HMO
Upper Gastrointestinal Endoscopy (UGI) in Adults, 2.01.533  PBC | Premera HMO
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

43235, 43238, 43239, 43242

Effective June 5, 2026

Carelon Medical Benefits Management Radiation Oncology
Now reviewed by Carelon for medical necessity and prior authorization.

77436, 77437, 77438, 77439

Carpal Tunnel Release Surgical Techniques, 7.01.595  PBC | Premera HMO
Site of Service Ambulatory Service Center (ASC) Select Surgical or Diagnostic Procedures in Adults, 11.01.525  PBC | Premera HMO
Now requires review for site of service, in addition to current review for medical necessity and prior authorization.

29848, 64721

Effective May 1, 2026

Diagnosis and Treatment of Sacroiliac Joint Pain, 6.01.527  PBC | Premera HMO
No longer considered investigational. Now requires review for medical necessity.

27279, 27278

Electrical and Electromagnetic Stimulation for the Treatment of Arthritis, 1.01.27  PBC | Premera HMO
No longer requires prior authorization. Still considered investigational.

E0762

Hematopoietic Cell Transplantation for Waldenstrom Macroglobulinemia, 8.01.531  PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

S2150

Negative Pressure Wound Therapy, 1.01.508 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.

97605, 97606

No longer requires prior authorization. Still considered investigational.

97607, 97608

Removed codes
Effective June 5, 2026

Electronic Brachytherapy for Nonmelanoma Skin Cancer, 8.01.62  PBC | Premera HMO
Now reviewed by Carelon for medical necessity and prior authorization.

77436, 77437, 77438, 77439

Effective May 1, 2026

Folate Antimetabolites, 5.01.617  PBC | Premera HMO
No longer requires review.

J8611, J9323

Hematopoietic Cell Transplantation for Acute Myeloid Leukemia, 8.01.26  PBC | Premera HMO
No longer requires review.

38230, 38232, 38240, 38241, S2142, S2150

Knee Arthroplasty in Adults, 7.01.550 PBC | Premera HMO
Code terminated.

27445

Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders, 5.01.586  PBC | Premera HMO
No longer requires review.

J2001

Orthognathic Surgery, 9.01.501  PBC | Premera HMO
No longer requires review.

D5954, D5955, D5958, D5959, D7283, D7881

Pharmacologic Treatment of Duchenne Muscular Dystrophy, 5.01.570  PBC | Premera HMO
No longer requires review.

0820T, 0821T, 0822T

Pharmacologic Treatment of Postpartum Depression, 5.01.608  PBC | Premera HMO
No longer requires review.

J1632

No updates this month.

No updates this month.

No updates this month.

No updates this month.

No updates this month.

No updates this month.

No updates this month.

No updates this month.