• 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/5.01.575.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.575 Dupixent (dupilumab) Effective Date: April 1, 2025 ... 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 Amyotrophic Lateral Sclerosis (ALS) Medications ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
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/5.01.599.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/5.01.609.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.609 Spravato (esketamine) Nasal Spray BCBSA Ref. Policy: 5.01.34 Effective Date: Jun. 1, 2025 Last Revised: May 13, 2025 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/5.01.614.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.614 Erythroid Maturation Agents Effective Date: May 1, ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.616.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.616 Pharmacologic Treatment of Gout Effective Date: Feb. ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.621.pdf#search=policy
PHARMACY POLICY - 5.01.621 Drugs for Weight Management Effective Date: Jun. 1, 2025 Last ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.630.pdf#search=policy
MEDICAL POLICY - 5.01.630 Intravenous Iron Replacement Products Effective Date: May 1, ... POLICY CRITERIA | CODING | RELATED INFORMATION | EVIDENCE REVIEW | REFERENCES | APPENDIX | ...
https://www.premera.com/medicalpolicies/5.01.634.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.634 Gene Therapies for Cerebral Adrenoleukodystrophy BCBSA Ref. Policy: 5.01.45 Effective Date: May 1, 2025 Last Revised: Apr. 21, 2025 Replaces: ...
https://www.premera.com/medicalpolicies/5.01.649.pdf#search=policy
PHARMACY POLICY - 5.01.649 Pharmacologic Treatment of Seizures Effective Date: Mar. 1, ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.650.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.650 Bispecific Antibodies Effective Date: May 1, 2025 ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/6.01.528.pdf#search=policy
MEDICAL POLICY - 6.01.528 Whole-Body Dual X-Ray Absorptiometry and Bioelectrical Impedance Analysis to Determine Body Composition BCBSA Ref. Policy: 6.01.40 Effective Date: Dec. 1, ...
https://www.premera.com/medicalpolicies/6.01.54.pdf#search=policy
MEDICAL POLICY - 6.01.54 Dopamine Transporter Single-Photon Emission Computed Tomography BCBSA Ref. Policy: 6.01.54 Effective Date: Jan. 1, 2025 Last Revised: Dec. 9, 2024 ...
https://www.premera.com/medicalpolicies/7.01.143.pdf#search=policy
MEDICAL POLICY - 7.01.143 Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy BCBSA Ref. Policy: 7.01.143 Effective Date: July 1, 2024 Last Revised: Sept. ...
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, 2024 Last Revised: Nov. 11, 2024 Replaces: N/A RELATED ...
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: Oct. 1, 2024 Last Revised: Sept. 9, 2024 Replaces: N/A RELATED ...
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, 2025 Last Revised: Feb. 10, 2025 ...
https://www.premera.com/medicalpolicies/7.01.565.pdf#search=policy
MEDICAL POLICY - 7.01.565 Ablation of Peripheral Nerves to Treat Pain BCBSA Ref. Policy: 7.01.154 Effective Date: Dec. 1, 2024 Last Revised: Jan. 1, 2025 Replaces: 7.01.154 ...
https://www.premera.com/medicalpolicies/7.01.582.pdf#search=policy
MEDICAL POLICY - 7.01.582 Bioengineered Skin and Soft Tissue Substitutes BCBSA Ref. Policy: 7.01.113 Effective Date: Jul. 3, 2025* Last Revised: Jun. 1, 2025 Replaces: 7.01.113 ...