• 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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378 results found for policy
https://www.premera.com/medicalpolicies/2.04.521_2025-04-06.pdf#search=policy
MEDICAL POLICY - 2.04.521 Evaluation of Biomarkers for Alzheimer Disease BCBSA Ref. Policy: 2.04.14 Effective Date: April 6, 2025* Last Revised: Dec. 10, 2024 Replaces: N/A *This ...
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/5.01.569.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.569 Pharmacotherapy of Type I and Type II Diabetes ... 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) BCBSA Ref. Policy: 5.01.28 Effective Date: Sept. 1, 2024 Last Revised: Aug. 26, 2024 ...
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/5.01.608.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/5.01.611.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/5.01.638.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.638 Omisirge (omidubicel) BCBSA Ref. Policy: 8.01.68 Effective Date: Dec. 1, 2024 Last Revised: Nov. 25, 2024 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/5.01.644.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.644 Medical Pharmacologic Treatment of Multiple ... Medical Necessity criteria within this policy DOES NOT apply to Alaska fully- insured ...
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/7.01.163.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, 2025 Last Revised: Dec. 9, 2024 ...
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: Sept. 11, 2024 ...
https://www.premera.com/medicalpolicies/7.01.590.pdf#search=policy
MEDICAL POLICY - 7.01.590 Shoulder Arthroplasty BCBSA Ref. Policy: N/A Effective Date: Jan. 3, 2025 Last Revised: Sept. 10, 2024 Replaces: N/A RELATED MEDICAL POLICIES: None ...
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/1.01.27.pdf#search=policy
MEDICAL POLICY - 1.01.27 Electrical and Electromagnetic Stimulation for the Treatment of Arthritis BCBSA Ref. Policy: 1.01.27 Effective Date: June 1, 2024 Last Revised: May 13, ...
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: June 1, 2024 Last Revised: May 13, 2024 ...
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, 2024 Last Revised: Aug. 12, 2024 ...
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, 2025 Last Revised: Jan. 13, 2025 ...
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/5.01.549.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 ∞ ...