• 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/5.01.549.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.549 Off-Label Use of Drugs and Biologic Agents Effective ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
https://www.premera.com/medicalpolicies/5.01.574.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.574 Pharmacotherapy of Spinal Muscular Atrophy (SMA) ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/8.01.52.pdf#search=policy
MEDICAL POLICY - 8.01.52 Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow) BCBSA Ref. Policy: 8.01.52 ...
https://www.premera.com/medicalpolicies/1.01.537.pdf#search=policy
MEDICAL POLICY - 1.01.537 Low Intensity Pulsed Ultrasound Fracture Healing Device BCBSA Ref. Policy: 1.01.05 Effective Date: June 1, 2022 Last Revised: May 10, 2022 Replaces: ...
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 fully-insured ...
https://www.premera.com/medicalpolicies/10.01.533.pdf#search=policy
MEDICAL POLICY - 10.01.533 Non-covered Experimental/Investigational Services Effective ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/2.04.119.pdf#search=policy
MEDICAL POLICY - 2.04.119 Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis BCBSA Ref. Policy: 2.04.119 Effective Date: Sept. 1, 2022 Last Revised: Aug. 8, 2022 ...
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: Feb. 1, 2023 Last Revised: Jan. 23, 2023 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/5.01.616.pdf#search=policy
MEDICAL POLICY - 5.01.616 Pharmacologic Treatment of Gout Effective Date: Dec. 1, 2022 ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/8.01.11.pdf#search=policy
MEDICAL POLICY - 8.01.11 Transcatheter Arterial Chemoembolization (TACE) to Treat Primary or Metastatic Liver Malignancies BCBSA Ref. Policy: 8.01.11 Effective Date: Oct. 1, 2022 ...
https://www.premera.com/medicalpolicies/2.04.123.pdf#search=policy
MEDICAL POLICY - 2.04.123 Serum Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective Tissue Diseases BCBSA Ref. Policy: 2.04.123 Effective Date: Aug. 1, ...
https://www.premera.com/medicalpolicies/2.04.514.pdf#search=policy
MEDICAL POLICY - 2.04.514 Protein Biomarkers for Diagnosis and Risk Assessment of Prostate Cancer BCBSA Ref. Policy: 2.04.33 Effective Date: Jan. 1, 2023 Last Revised: Dec. 23, ...
https://www.premera.com/medicalpolicies/5.01.569.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.569 Pharmacotherapy of Type I and Type II Diabetes ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/5.01.575.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.575 Dupixent® (dupilumab) Effective Date: Dec. 1, 2022 ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.588.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.588 Pharmacologic Prevention and Treatment of HIV/AIDS ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
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: Feb. 1, 2023 Last Revised: Jan. 23, 2023 ...
https://www.premera.com/medicalpolicies/7.01.85.pdf#search=policy
MEDICAL POLICY - 7.01.85 Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures BCBSA Ref. Policy: 7.01.85 Effective Date: July 1, 2022 Last Revised: June ...
https://www.premera.com/medicalpolicies/7.01.92.pdf#search=policy
MEDICAL POLICY - 7.01.92 Cryoablation of Tumors Located in the Kidney, Lung, Breast, Pancreas, or Bone BCBSA Ref. Policy: 7.01.92 Effective Date: Oct. 1, 2022 Last Revised: Sept. ...
https://www.premera.com/medicalpolicies/9.03.508.pdf#search=policy
MEDICAL POLICY - 9.03.508 Orthoptic Training, Vision Therapy, Visual Perceptual Training, Vision Restoration Therapy, and Neurovisual Rehabilitation BCBSA Ref. Policy: 9.03.03 ...
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: Sept. 1, 2022 Last Revised: Aug. 8, 2022 Replaces: N/A RELATED MEDICAL ...