Added codes
Effective October 3, 2025
Implantable Cardioverter Defibrillator (ICD), 7.01.44 PBC | Premera HMO
Now requires review for medical necessity.
C1721, C1722, C1824, C1882, C1895, C1896, C1899
Now requires review for medical necessity and prior authorization.
33216, 33217, 33230, 33231, 33240, 33249, 33270, 33271, 93260, 93282-93284, 93287, 93289, 0572T
Pharmacologic Treatment of Parkinson's Disease, 5.01.651 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J0364
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J1748
Prosthetic Urethral Lift, 7.01.598 PBC | Premera HMO
Now requires review for medical necessity.
C9739, C9740
Now requires review for medical necessity and prior authorization.
52441, 52442
Site of Service: Drugs and Biologic Agents, 11.01.523 PBC | Premera HMO
Now requires review for medical necessity, including site of service and prior authorization.
J3111, J0517, J0638, J9173, J9272, J2182, J2351, J9622, J0491, J9022, J9024, J3241, J2356, J3032, J9332, J9334, J2357, J1748
Systemic Pharmacologic Treatments of Plaque Psoriasis, 5.01.652 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J1747
Carelon Management Sleep Disorder Management
Now reviewed by Carelon Specialty Health for medical necessity and prior authorization.
0964T, 0965T, 0966T
Effective September 5, 2025
Bioengineered Skin and Soft Tissue Substitutes, 7.01.582 PBC | Premera HMO
Now requires review for investigational.
C1763
Hepatitis C Antiviral Therapy, 5.01.606 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
S0145
Medical Necessity Criteria for Pharmacy Edits, 5.01.605 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J0248, J1201, J2278, J3396
Myoelectric Prosthetic and Orthotic Components for the Upper Limb, 1.04.502 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
L6882
Effective August 1, 2025
Implantable Bone-Conduction and Bone-Anchored Hearing Aids, 7.01.547 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
69719
Miscellaneous Oncology Drugs, 5.01.540 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J0893
Pharmacologic Treatment of Osteoporosis, 5.01.596 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J0630
Effective July 3, 2025
Catheter Ablation for Atrial Fibrillation, 2.02.516 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
93655, 93656, 93657
Effective July 1, 2025
Amniotic Membrane and Amniotic Fluid, 7.01.583 PBC | Premera HMO
Now requires review for investigational.
Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382
Antibody-Drug Conjugates, 5.01.582 PBC | Premera HMO
Now requires review for medical necessity.
C9174
Bispecific Antibodies, 5.01.650 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J9276, J9382
Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma, 8.01.63 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
Q2058
Evaluation of Biomarkers for Alzheimer Disease, 2.04.521 PBC | Premera HMO
Now requires review for investigational.
0568U
Focal Treatments for Prostate Cancer, 8.01.61 PBC | Premera HMO
Now requires review for investigational.
0950T
Gene Therapies for Rare Diseases, 5.01.642 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J3391
Immune Checkpoint Inhibitors, 5.01.591 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J9275, J9289
Laboratory Testing Investigational Services, 2.04.520 PBC | Premera HMO
Now requires review for investigational.
0558U, 0559U, 0563U, 0564U, 0570U, 0572U, 0573U, 0574U
Miscellaneous Oncology Drugs, 5.01.540 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J1326, J9341, J9174
Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis, 2.04.127 PBC | Premera HMO
Now requires review for investigational.
0557U
Non-covered Experimental/Investigational Services, 10.01.533 PBC | Premera HMO
Now requires review for investigational.
0948T, 0949T, 0956T, 0957T, 0958T, 0959T, 0960T, 0961T, 0962T, 0964T, 0965T, 0966T, 0967T, 0968T, 0969T, 0970T, 0971T, 0972T, 0973T, 0974T, 0975T, 0976T, 0978T, 0979T, 0980T, 0981T, 0982T, 0983T, 0984T, 0985T, 0986T, 0987T, C8005
Non-covered Services and Procedures, 10.01.517 PBC | Premera HMO
No longer covered.
A6610, E0201, E1022, E1023
Pharmacologic Treatment of Hemophilia, 5.01.581 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J7172
Pharmacologic Treatment of Parkinson's Disease, 5.01.651 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
J7356
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
Q9997
Pharmacotherapy of Inflammatory Bowel Disorder, 5.01.563 PBC | Premera HMO
Pharmacologic Treatment of Psoriasis, 5.01.629 PBC | Premera HMO
Pharmacologic Treatment of Psoriatic Arthritis, 5.01.645 PBC | Premera HMO
Now requires review for medical necessity and prior authorization.
Q5098, Q5099, Q5100, Q5137, Q5138, Q9996, Q9998, Q9999
Semi-Implantable and Fully Implantable Middle Ear Hearing Aids, 7.01.84 PBC | Premera HMO
Now requires review for investigational.
0951T, 0952T, 0953T, 0954T, 0955T
Site of Service: Select Surgical Procedures, 11.01.524 PBC | Premera HMO
Now requires review for medical necessity, including site of service and prior authorization.
31233, 31235, 31240
Carelon Management Genetic Testing
Now reviewed by Carelon Specialty Health for medical necessity and prior authorization.
0552U, 0553U, 0554U, 0555U, 0560U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U
Revised codes
Effective October 3, 2025
Alpha1-Proteinase Inhibitors, 5.01.624 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J0491, J9332, J9334
CGRP Inhibitors for Migraine Prophylaxis, 5.01.584 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J3032
Drugs for Rare Diseases, 5.01.576 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J3241
IL-5 Inhibitors, 5.01.559 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J0517, J2182
Immune Checkpoint Inhibitors, 5.01.591 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J9024, J9173, J9272, J9289, J9622
Pharmacologic Treatment of Gout, 5.01.616 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J0638
Medical Pharmacologic Treatments of Multiple Sclerosis, 5.01.644 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J2351
Pharmacologic Treatment of Osteoporosis, 5.01.596 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J3111
No longer requires review for site of service. Review for medical necessity and prior authorization still required.
J0893
Thymic Stromal Lymphopoietin (TSLP) Inhibitors, 5.01.627 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J2356
Xolair (omalizumab), 5.01.513 PBC | Premera HMO
Now requires review for site of service. Currently requires review for medical necessity and prior authorization.
J2357
Removed codes
Effective July 1, 2025
Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma, 8.01.63 PBC | Premera HMO
Code terminated
C9301
Gonadotropin Releasing Hormone (GnRH) Analogs, 5.01.625 PBC | Premera HMO
Code terminated
J9225
Miscellaneous Oncology Drugs, 5.01.540 PBC | Premera HMO
Code terminated
C9303
Pharmacologic Treatment of Hemophilia, 5.01.581 PBC | Premera HMO
Code terminated
C9304
Use of Granulocyte Colony-Stimulating Factors (G-CSF), 5.01.551 PBC | Premera HMO
Code terminated
C9173