• 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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382 results found for policy
https://www.premera.com/medicalpolicies/5.01.646.pdf#search=policy
PHARMACY POLICY - 5.01.646 SGLT2 Inhibitors Effective Date: May 1, 2025 Last Revised: ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/7.01.126.pdf#search=policy
MEDICAL POLICY - 7.01.126 Image-Guided Minimally Invasive Decompression for Spinal Stenosis BCBSA Ref. Policy: 7.01.126 Effective Date: July 1, 2024 Last Revised: June 10, 2024 ...
https://www.premera.com/medicalpolicies/7.01.142.pdf#search=policy
MEDICAL POLICY - 7.01.142 Surgery for Groin Pain in Athletes BCBSA Ref. Policy: 7.01.142 Effective Date: May 1, 2025 Last Revised: Apr. 7, 2025 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/7.01.564.pdf#search=policy
MEDICAL POLICY - 7.01.564 Pulsed Radiofrequency Effective Date: Oct. 1, 2024 Last ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/7.01.567.pdf#search=policy
MEDICAL POLICY - 7.01.567 Surgical Treatments for Lymphedema and Lipedema BCBSA Ref. Policy: 7.01.162, 7.01.169, 7.01.173 Effective Date: March 5, 2025 Last Revised: Nov. 12, 2024 ...
https://www.premera.com/medicalpolicies/7.01.588.pdf#search=policy
MEDICAL POLICY - 7.01.588 Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy BCBSA Ref. Policy: 7.01.29 Effective Date: Sept. 1, 2024 Last Revised: ...
https://www.premera.com/medicalpolicies/7.01.592.pdf#search=policy
MEDICAL POLICY - 7.01.592 Surgical Treatment of Femoroacetabular Impingement BCBSA Ref. Policy: 7.01.118 Effective Date: Dec. 1, 2024 Last Revised: Nov. 11, 2024 Replaces: N/A ...
https://www.premera.com/medicalpolicies/7.03.07.pdf#search=policy
MEDICAL POLICY - 7.03.07 Lung and Lobar Lung Transplant BCBSA Ref. Policy: 7.03.07 Effective Date: Nov. 1, 2024 Last Revised: Oct. 7, 2024 Replaces: Extracted from 7.03.509 ...
https://www.premera.com/medicalpolicies/8.01.531.pdf#search=policy
MEDICAL POLICY - 8.01.531 Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia BCBSA Ref. Policy: 8.01.54 Effective Date: Oct. 1, 2024 Last Revised: Sept. 23, ...
https://www.premera.com/medicalpolicies/10.01.520.pdf#search=policy
BENEFIT COVERAGE GUIDELINE - 10.01.520 Review for Coverage in the Absence of a Medical Policy, Pharmacy Policy, or Utilization Management Guideline Effective Date: Aug. 1, 2024 ...
https://www.premera.com/medicalpolicies/2.04.509.pdf#search=policy
MEDICAL POLICY - 2.04.509 Cardiovascular Risk Panels BCBSA Ref. Policy: 2.04.65 Effective Date: May 1, 2024 Last Revised: Aug. 2, 2024 Replaces: 2.04.509 RELATED MEDICAL POLICIES: ...
https://www.premera.com/medicalpolicies/2.04.520.pdf#search=policy
MEDICAL POLICY - 2.04.520 Laboratory Testing Investigational Services BCBSA Ref. Policy: 2.04.159 Effective Date: Jan. 1, 2025 Last Revised: Jun. 6, 2025 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/5.01.545.pdf#search=policy
PHARMACY POLICY - 5.01.545 Pharmacologic Treatment of Benign Prostatic Hyperplasia ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.562.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.562 Imlygic (talimogene laherparepvec) Effective Date: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.570.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.570 Pharmacologic Treatment of Duchenne Muscular Dystrophy BCBSA Ref. Policy: 5.01.27 Effective Date: Feb. 1, 2025 Last Revised: Jan. 27, 2025 ...
https://www.premera.com/medicalpolicies/5.01.571.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.571 C3 and C5 Complement Inhibitors BCBSA Ref. Policy: 5.01.39 Effective Date: Apr. 1, 2025 Last Revised: Mar. 11, 2025 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/5.01.576.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.576 Drugs for Rare Diseases BCBSA Ref. Policy: 5.01.37 and 5.01.40 Effective Date: May 1, 2025 Last Revised: Apr. 8, 2025 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/5.01.581.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.581 Pharmacologic Treatment of Hemophilia BCBSA Ref. Policy: 8.01.65 Effective Date: May 1, 2025 Last Revised: Apr. 8, 2025 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/5.01.582.pdf#search=policy
MEDICAL POLICY - 5.01.582 Antibody-Drug Conjugates Effective Date: Aug. 1, 2024 Last ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/5.01.585.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.585 Pharmacologic Treatment of Phenylketonuria Effective ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...