• Medical Policies

    Premera offers access to more than 300 medical policies online. Since we’re continually updating these pages, we encourage you to visit often. The policies are in Adobe PDF format. Individual plans use different medical policies. View individual plan medical policies and also View our HMO medical policies.

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350 results found for policy
https://www.premera.com/medicalpolicies/5.01.612.pdf#search=policy
PHARMACY POLICY - 5.01.612 Pharmacologic Treatment of Cystinosis Effective Date: Nov. 1, ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.613.pdf#search=policy
PHARMACY POLICY - 5.01.613 Oral Iron Chelating Agents Effective Date: Jan. 1, 2023 Last ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.617.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.617 Folate Antimetabolites Effective Date: Jan. 1, 2023 ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.619.pdf#search=policy
MEDICAL POLICY - 5.01.619 Intravitreal and Suprachoroidal Corticosteroids Effective Date: ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.624.pdf#search=policy
MEDICAL POLICY - 5.01.624 Alpha-1 Proteinase Inhibitors Effective Date: Jan. 1, 2023 Last ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.629.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.629 Pharmacologic Treatment of Psoriasis Effective Date: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/6.01.40.pdf#search=policy
MEDICAL POLICY - 6.01.40 Whole Body Dual X-Ray Absorptiometry to Determine Body Composition BCBSA Ref. Policy: 6.01.40 Effective Date: Jan. 1, 2023 Last Revised: Dec. 12, 2022 ...
https://www.premera.com/medicalpolicies/6.01.54.pdf#search=policy
MEDICAL POLICY - 6.01.54 Dopamine Transporter Imaging with Single-Photon Emission Computed Tomography BCBSA Ref. Policy: 6.01.54 Effective Date: Jan. 1, 2023 Last Revised: Dec. ...
https://www.premera.com/medicalpolicies/7.01.07.pdf#search=policy
MEDICAL POLICY - 7.01.07 Electrical Bone Growth Stimulation of the Appendicular Skeleton BCBSA Ref. Policy: 7.01.07 Effective Date: July 1, 2022 Last Revised: June 13, 2022 ...
https://www.premera.com/medicalpolicies/7.01.134.pdf#search=policy
MEDICAL POLICY - 7.01.134 Steroid-Eluting Sinus Stents and Implants BCBSA Ref. Policy: 7.01.134 Effective Date: May 1, 2022 Last Revised: April 11, 2022 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/7.01.158.pdf#search=policy
MEDICAL POLICY - 7.01.158 Balloon Dilation of the Eustachian Tube BCBSA Ref. Policy: 7.01.158 Effective Date: Dec. 1, 2022 Last Revised: Nov. 7, 2022 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/7.01.569.pdf#search=policy
MEDICAL POLICY - 7.01.569 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions BCBSA Ref. Policy: 7.01.48 Effective Date: July 1, 2022 Last Revised: June 27, ...
https://www.premera.com/medicalpolicies/7.01.572.pdf#search=policy
MEDICAL POLICY - 7.01.572 Irreversible Electroporation (NanoKnife® System) Effective ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/7.01.72.pdf#search=policy
POLICY - 7.01.72 Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty,and Intraosseous Basivertebral Nerve Ablation BCBSA Ref. Policy: ...
https://www.premera.com/medicalpolicies/7.03.05.pdf#search=policy
MEDICAL POLICY - 7.03.05 Small Bowel, Liver and Multivisceral Transplant BCBSA Ref. Policy: 7.03.05, 7.03.14 Effective Date: Nov. 1, 2022 Last Revised: Oct. 10, 2022 Replaces: ...
https://www.premera.com/medicalpolicies/7.03.13.pdf#search=policy
MEDICAL POLICY - 7.03.13 Composite Tissue Allotransplantation of the Hand and Face BCBSA Ref. Policy: 7.03.13 Effective Date: Nov. 1, 2022 Last Revised: Oct. 24, 2022 Replaces: N/...
https://www.premera.com/medicalpolicies/8.01.42.pdf#search=policy
MEDICAL POLICY - 8.01.42 Hematopoietic Cell Transplantation for Primary Amyloidosis BCBSA Ref. Policy: 8.01.42 Effective Date: Apr. 1, 2022 Last Revised: Oct. 1, 2022 Replaces: ...
https://www.premera.com/medicalpolicies/8.01.533.pdf#search=policy
MEDICAL POLICY - 8.01.533 Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma BCBSA Ref. Policy: 8.01.50 Effective Dec. 1, 2022 Last Revised: Nov. 7, 2022 Replaces: ...
https://www.premera.com/medicalpolicies/5.01.545.pdf#search=policy
PHARMACY POLICY - 5.01.545 Tadalafil Products for Benign Prostatic Hyperplasia Effective ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/1.01.29.pdf#search=policy
MEDICAL POLICY - 1.01.29 Tumor Treating Fields Therapy BCBSA Ref. Policy: 1.01.29 Effective Date: Oct. 1, 2022 Last Revised: Sept. 12, 2022 Replaces: N/A RELATED MEDICAL POLICIES: ...