• 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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356 results found for policy
https://www.premera.com/medicalpolicies/5.01.556.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.556 Rituximab: Non-oncologic and Miscellaneous Uses BCBSA Ref. Policy: 5.01.24 Effective Date: July 1, 2022 Last Revised: June 14, 2022 Replaces: ...
https://www.premera.com/medicalpolicies/5.01.558.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.558 Pharmacologic Treatment of High Cholesterol ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.571.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.571 C3 and C5 Complement Inhibitors Effective Date: Jan. ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.578.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.578 Radicava® (edaravone) Effective Date: Aug. 1, 2022 ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.581.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.581 Hemlibra® (emicizumab-kxwh) Effective Date: Dec. 1, ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/5.01.584.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.584 CGRP Inhibitors for Migraine Prophylaxis Effective ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.592.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.592 Phosphoinositide 3-kinase (PI3K) Inhibitors ... Select a hyperlink below to be directed to that section. POLICY CRITERIA | DOCUMENTATION ...
https://www.premera.com/medicalpolicies/5.01.599.pdf#search=policy
PHARMACY POLICY - 5.01.599 Pharmacologic Treatment of Sleep Disorders Effective Date: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.610.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.610 Pharmacologic Treatment in Assisted Reproduction ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
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/7.01.143.pdf#search=policy
MEDICAL POLICY - 7.01.143 Responsive Neurostimulation for the Treatment of Refractory Partial Epilepsy BCBSA Ref. Policy: 7.01.143 Effective Date: July 1, 2022 Last Revised: June ...
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/7.01.160.pdf#search=policy
MEDICAL POLICY - 7.01.160 Synthetic Cartilage Implants for Joint Pain BCBSA Ref. Policy: 7.01.160 Effective Date: Sept. 1, 2022 Last Revised: Aug. 22, 2022 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/7.01.583.pdf#search=policy
MEDICAL POLICY - 7.01.583 Amniotic Membrane and Amniotic Fluid BCBSA Ref. Policy: 7.01.149 Effective Date: May 1, 2022 Last Revised: Jan. 1, 2023 Replaces: N/A RELATED MEDICAL ...
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/5.01.614.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.614 Erythroid Maturation Agents Effective Date: Jan. 1, ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/1.01.26.pdf#search=policy
MEDICAL POLICY - 1.01.26 Cooling Devices Used in the Outpatient Setting BCBSA Ref. Policy: 1.01.26 Effective Date: June 1, 2022 Last Revised: May 9, 2022 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/1.01.525.pdf#search=policy
MEDICAL POLICY - 1.01.525 Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis BCBSA Ref. Policy: 1.01.28 Effective Date: June 1, 2022 Last ...
https://www.premera.com/medicalpolicies/2.02.506.pdf#search=policy
MEDICAL POLICY - 2.02.506 Wearable Cardioverter-Defibrillators as a Bridge to Implantable Cardioverter-Defibrillator Placement BCBSA Ref. Policy: 2.02.15, 7.01.44 Effective Date: ...