• 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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381 results found for policy
https://www.premera.com/medicalpolicies/1.01.538.pdf#search=policy
MEDICAL POLICY - 1.01.538 Cooling Devices Used in the Outpatient Setting BCBSA Ref. Policy: 1.01.26 Effective Date: June 1, 2024 Last Revised: May 13, 2024 Replaces: 1.01.26 ...
https://www.premera.com/medicalpolicies/2.01.100.pdf#search=policy
MEDICAL POLICY - 2.01.100 Dry Needling of Trigger Points for Myofascial Pain BCBSA Ref. Policy: 2.01.100 Effective Date: July 1, 2024 Last Revised: June 10, 2024 Replaces: N/A ...
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/2.04.136.pdf#search=policy
MEDICAL POLICY - 2.04.136 Nutrient/Nutritional Panel Testing BCBSA Ref. Policy: 2.04.136 Effective Date: Mar. 1, 2025 Last Revised: Feb. 10, 2025 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/4.02.06.pdf#search=policy
MEDICAL POLICY - 4.02.06 Uterus Transplantation for Absolute Uterine Factor Infertility BCBSA Ref. Policy: 4.02.06 Effective Date: Nov. 1, 2024 Last Revised: Oct. 7, 2024 ...
https://www.premera.com/medicalpolicies/5.01.42.pdf#search=policy
MEDICAL POLICY - 5.01.42 Gene Therapies for Thalassemia BCBSA Ref. Policy: 5.01.42 Effective Date: May 1, 2025 Last Revised: Apr. 21, 2025 Replaces: N/A RELATED MEDICAL POLICIES: ...
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/5.01.551.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.551 Use of Granulocyte Colony-Stimulating Factors (G-CSF) Effective Date: Mar. 1, 2025* Last Revised: Apr. 15, 2025 Replaces: N/A *This policy has ...
https://www.premera.com/medicalpolicies/5.01.556_2025-07-01.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, 2025* Last Revised: Feb. 11, 2025 Replaces: ...
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: May 6, 2025 Last Revised: Mar. 24, ...
https://www.premera.com/medicalpolicies/5.01.608.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.608 Pharmacologic Treatment of Postpartum Depression BCBSA Ref. Policy: 5.01.33 Effective Date: Mar. 1, 2025 Last Revised: Feb. 24, 2025 Replaces: ...
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/5.01.651.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.651 Pharmacologic Treatment of Parkinson's Disease ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/1.01.24.pdf#search=policy
MEDICAL POLICY - 1.01.24 Interferential Current Stimulation BCBSA Ref. Policy: 1.01.24 Effective Date: Aug. 1, 2024 Last Revised: July 22, 2024 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/1.01.539.pdf#search=policy
MEDICAL POLICY - 1.01.539 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions BCBSA Ref. Policy: 1.01.15 Effective Date: Nov. 1, 2024 Last ...
https://www.premera.com/medicalpolicies/1.01.540.pdf#search=policy
MEDICAL POLICY - 1.01.540 Continuous Passive Motion in the Home Setting BCBSA Ref. Policy: 1.01.10 Effective Date: June 1, 2024 Last Revised: May 13, 2024 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/2.01.91.pdf#search=policy
MEDICAL POLICY - 2.01.91 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis BCBSA Ref. Policy: 2.01.91 Effective Date: Feb. 1, 2025 Last Revised: ...
https://www.premera.com/medicalpolicies/2.02.26.pdf#search=policy
MEDICAL POLICY - 2.02.26 Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation BCBSA Ref. Policy: 2.02.26 Effective Date: August 1, 2024 ...
https://www.premera.com/medicalpolicies/2.02.507.pdf#search=policy
MEDICAL POLICY - 2.02.507 Coronary Angiography for Known or Suspected Coronary Artery ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/2.04.513.pdf#search=policy
MEDICAL POLICY - 2.04.513 Drug Testing in Pain Management and Substance Use Disorder Treatment Settings BCBSA Ref. Policy: 2.04.98 Effective Date: Feb. 1, 2025 Last Revised: Jan. ...