• 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/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: Feb. ...
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: Aug. 1, 2022 ...
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, 2023 Last Revised: Jan. ...
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/5.01.551.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.551 Use of Granulocyte Colony-Stimulating Factors ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.595.pdf#search=policy
PHARMACY/MEDICAL POLICY - 5.01.595 Injectable Clostridial Collagenase for Fibroproliferative Disorders BCBSA Ref. Policy: 5.01.19 Effective Date: June 1, 2022 Last Revised: May ...
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 | ...
https://www.premera.com/medicalpolicies/5.01.625.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.625 Gonadotropin Releasing Hormone (GnRH) Analogs ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/7.01.163.pdf#search=policy
MEDICAL POLICY - 7.01.163 Absorbable Nasal Implant for Treatment of Nasal Valve Collapse BCBSA Ref. Policy: 7.01.163 Effective Date: Jan. 1, 2023 Last Revised: Dec. 12, 2022 ...
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: Apr. 1, 2022 ...
https://www.premera.com/medicalpolicies/8.01.43.pdf#search=policy
MEDICAL POLICY - 8.01.43 Radioembolization for Primary and Metastatic Tumors of the Liver BCBSA Ref. Policy: 8.01.43 Effective Date: Sept. 1, 2022 Last Revised: Aug. 22, 2022 ...
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, 2022 Last Revised: Oct. 1, ...
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/1.04.502.pdf#search=policy
MEDICAL POLICY - 1.04.502 Myoelectric Prosthetic and Orthotic Components for the Upper Limb BCBSA Ref. Policy: 1.04.04 Effective Date: Oct. 1, 2022 Last Revised: Sept. 13, 2022 ...
https://www.premera.com/medicalpolicies/2.04.125.pdf#search=policy
MEDICAL POLICY - 2.04.125 Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer BCBSA Ref. Policy: 2.04.125 Effective Date: Feb. 1, 2023 Last Revised: Jan. 9, 2023 ...
https://www.premera.com/medicalpolicies/3.01.510_2023-05-02.pdf#search=policy
MEDICAL POLICY - 3.01.510 Applied Behavior Analysis (ABA) Effective Date: May 2, 2023* ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
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 ...