• 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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365 results found for policy
https://www.premera.com/medicalpolicies/5.01.598.pdf#search=policy
PHARMACY POLICY - 5.01.598 Pharmacologic Treatment to Reduce Serum Phosphorus Effective ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.608.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.608 Pharmacologic Treatment of Postpartum Depression ... 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/5.01.616.pdf#search=policy
MEDICAL POLICY - 5.01.616 Pharmacologic Treatment of Gout Effective Date: Mar. 1, 2024 ... 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/6.01.25.pdf#search=policy
MEDICAL POLICY - 6.01.25 Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine BCBSA Ref. Policy: 6.01.25 Effective Date: July 1, 2024 Last ...
https://www.premera.com/medicalpolicies/7.01.170.pdf#search=policy
MEDICAL POLICY - 7.01.170 Laser Interstitial Thermal Therapy for Neurological Conditions BCBSA Ref. Policy: 7.01.170 Effective Date: Mar. 1, 2024 Last Revised: Feb. 12, 2024 ...
https://www.premera.com/medicalpolicies/7.01.592.pdf#search=policy
MEDICAL POLICY - 7.01.592 Surgical Treatment of Femoroacetabular Impingement BCBSA Ref. Policy: 7.01.118 Effective Date: Oct. 8, 2024* Last Revised: June 11, 2024 Replaces: N/A ...
https://www.premera.com/medicalpolicies/8.01.15.pdf#search=policy
MEDICAL POLICY - 8.01.15 Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma BCBSA Ref. Policy: 8.01.15 Effective Date: April 1, 2024 ...
https://www.premera.com/medicalpolicies/8.01.532.pdf#search=policy
MEDICAL POLICY - 8.01.532 Hematopoietic Cell Transplantation in the Treatment of Germ-Cell Tumors BCBSA Ref. Policy: 8.01.35 Effective Date: April 1, 2024 Last Revised: Mar. 25, ...
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: July 1, 2024 Last Revised: June 11, 2024 Replaces: N/A ...
https://www.premera.com/medicalpolicies/1.01.530.pdf#search=policy
MEDICAL POLICY - 1.01.530 Children's Therapeutic Positioning Equipment Effective Date: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/10.01.532.pdf#search=policy
MEDICAL POLICY - 10.01.532 ASAM Criteria: Services Reviewed for Medical Necessity ... N/A RELATED MEDICAL POLICIES: None This policy only applies to Washington Individual ...
https://www.premera.com/medicalpolicies/2.01.526.pdf#search=policy
MEDICAL POLICY - 2.01.526 Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders BCBSA Ref. Policy: 2.01.50 Effective Date: July ...
https://www.premera.com/medicalpolicies/5.01.539.pdf#search=policy
PHARMACY POLICY - 5.01.539 Pharmacologic Treatment of Cystic Fibrosis with Ivacaftor ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.547.pdf#search=policy
PHARMACY POLICY - 5.01.547 Medical Necessity Criteria and Dispensing Quantity Limits for ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.548.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.548 Pharmacotherapy of Cushing's Disease and Acromegaly ... 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/5.01.611.pdf#search=policy
PHARMACY POLICY - 5.01.611 Pharmacologic Treatment of Urea Cycle Disorders Effective ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.618.pdf#search=policy
PHARMACY POLICY - 5.01.618 Selective Estrogen Receptor Modulators and Down Regulators ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...