• 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/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: ...
https://www.premera.com/medicalpolicies/2.04.516.pdf#search=policy
MEDICAL POLICY - 2.04.516 Measurement of Serum Antibodies to Selected Biologic Agents BCBSA Ref. Policy: 2.04.84 Effective Date: Feb. 1, 2023 Last Revised: Jan. 9, 2023 Replaces: ...
https://www.premera.com/medicalpolicies/5.01.532.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.532 Cutaneous T-Cell Lymphomas (CTCL): Systemic ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.568.pdf#search=policy
PHARMACY POLICY - 5.01.568 Venclexta® (venetoclax) BCL-2 Inhibitor Effective Date: Dec. ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
https://www.premera.com/medicalpolicies/5.01.576.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.576 Drugs for Rare Diseases Effective Date: Mar. 1, 2023 ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | APPENDIX | ...
https://www.premera.com/medicalpolicies/5.01.593.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.593 Pharmacologic Treatment of Transthyretin-Mediated Amyloidosis BCBSA Ref. Policy: 5.01.30 Effective Date: Feb. 1, 2023 Last Revised: Jan. 10, ...
https://www.premera.com/medicalpolicies/5.01.596.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.596 Pharmacologic Treatment of Osteoporosis Effective ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.608.pdf#search=policy
MEDICAL POLICY - 5.01.608 Pharmacologic Treatment of Postpartum Depression Effective ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.609.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.609 Spravato® (esketamine) Nasal Spray Effective Date: ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.623.pdf#search=policy
PHARMACY POLICY - 5.01.623 Topical Drugs for Actinic Keratosis and Other Dermatologic ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.628.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.628 Pharmacologic Treatment of Atopic Dermatitis ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/7.01.101.pdf#search=policy
MEDICAL POLICY - 7.01.101 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome BCBSA Ref. Policy: 7.01.101 Effective Date: Sept. 1, 2022 Last Revised: Aug. 8, 2022 ...
https://www.premera.com/medicalpolicies/7.01.154.pdf#search=policy
MEDICAL POLICY - 7.01.154 Ablation of Peripheral Nerves to Treat Pain BCBSA Ref. Policy: 7.01.154 Effective Date: Dec. 1, 2022 Last Revised: Nov. 7, 2022 Replaces: 7.01.565 ...
https://www.premera.com/medicalpolicies/7.01.165.pdf#search=policy
MEDICAL POLICY - 7.01.165 Radiofrequency Coblation Tenotomy for Musculoskeletal Conditions BCBSA Ref. Policy: 7.01.165 Effective Date: Mar. 1, 2022 Last Revised: Feb. 7, 2022 ...
https://www.premera.com/medicalpolicies/8.01.63.pdf#search=policy
MEDICAL POLICY - 8.01.63 Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma BCBSA Ref. Policy: 8.01.63 Effective Date: Dec. 1, 2022 Last Revised: Nov. 8, 2022 Replaces: ...
https://www.premera.com/medicalpolicies/8.01.66.pdf#search=policy
MEDICAL POLICY - 8.01.66 Chimeric Antigen Receptor Therapy for Multiple Myeloma BCBSA Ref. Policy: 8.01.66 Effective Date: Oct. 1, 2022 Last Revised: Sept. 13, 2022 Replaces: N/A ...
https://www.premera.com/medicalpolicies/1.01.10.pdf#search=policy
MEDICAL POLICY - 1.01.10 Continuous Passive Motion in the Home Setting BCBSA Ref. Policy: 1.01.10 Effective Date: June 1, 2022 Last Revised: May 9, 2022 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/1.01.11.pdf#search=policy
MEDICAL POLICY - 1.01.11 Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses BCBSA Ref Policy: 1.01.11 Effective Date: June 1, 2022 Last Revised: May 9, ...
https://www.premera.com/medicalpolicies/1.01.15.pdf#search=policy
MEDICAL POLICY - 1.01.15 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions BCBSA Ref. Policy: 1.01.15 Effective Date: Sept. 1, 2022 Last ...