• Medical Policies

    Note: As of January 1, 2020, there will be changes to our medical policies for members with individual plans. Learn more about these upcoming changes, or browse our medical policies for individual plans.

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337 results found for policy
https://www.premera.com/medicalpolicies/5.01.529.pdf
below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ... Examples of opioids are oxycodone, hydrocodone, and fentanyl. This policy describes when ...
https://www.premera.com/medicalpolicies/5.01.605.pdf
This policy describes coverage criteria for drugs in the plan's pharmacy prior ... section is for your general knowledge and is not to be taken as policy coverage criteria. ...
https://www.premera.com/medicalpolicies/5.01.527.pdf
POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ... In some people it won't work at all. This policy describes when dalfampridine or Ampyra® ...
https://www.premera.com/medicalpolicies/5.01.559_2020-04-03.pdf
view the current policy, click here. RELATED MEDICAL POLICIES: 5.01.513 Xolair® (omalizumab) Select a hyperlink below to be directed to that section. POLICY CRITERIA | CODING | ...
https://www.premera.com/medicalpolicies/5.01.538.pdf
below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ... This policy describes when this specific form of chemotherapy may be considered medically ...
https://www.premera.com/medicalpolicies/2.02.32.pdf
2 Leadless Cardiac Pacemakers BCBSA Ref. Policy: 2.02.32 Effective Date: Jan. 3, 2020 Last ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/2.04.123.pdf
Connective Tissue Diseases BCBSA Ref. Policy: 2.04.123 Effective Date: Sept. 1, 2019 ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/5.01.533.pdf
below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ... This policy discusses when mTOR kinase inhibitors may be considered medically necessary. ...
https://www.premera.com/medicalpolicies/5.01.532.pdf
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ... This policy describes when particular chemotherapy drugs may be considered medically ...
https://www.premera.com/medicalpolicies/8.01.11.pdf
Policy: 8.01.11 Effective Date: Oct. 1, 2019 Last Revised: Sept. 5, 2019 Replaces: ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/3.01.510.pdf
below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ... This policy describes when ABA may be considered medically necessary. It also discusses ...
https://www.premera.com/medicalpolicies/5.01.540.pdf
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ... This policy gives information about many different types of chemo drugs and the criteria ...
https://www.premera.com/medicalpolicies/7.01.557.pdf
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ... This policy describes the procedures that are covered as part of gender reassignment ...
https://www.premera.com/medicalpolicies/7.03.05.pdf
Policy: 7.03.05, 7.03.14 Effective Date: Nov. 1, 2019 Last Revised: Oct. 4, 2019 Replaces: ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.536.pdf
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ... is for your general knowledge and is not to be construed as policy coverage criteria. ...
https://www.premera.com/medicalpolicies/5.01.548.pdf
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ... This policy describes when specific drugs to treat these conditions may be considered ...
https://www.premera.com/medicalpolicies/7.01.533.pdf
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | REFERENCES | ... This policy describes when breast reconstruction is covered to address a medical ...
https://www.premera.com/medicalpolicies/5.01.539.pdf
below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ... Drugs have been developed that target specific changes on the CFTR gene. This policy ...
https://www.premera.com/medicalpolicies/5.01.520.pdf
POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ... This policy describes when brand-name second-generation antidepressants may be considered ...
https://www.premera.com/medicalpolicies/7.01.161.pdf
Policy: 7.01.161 Effective Date: Oct. 1, 2019 Last Revised: Sept. 5, 2019 Replaces: N/A ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...