• 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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382 results found for policy
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. ...
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/5.01.551_2025-07-01.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.551 Use of Granulocyte Colony-Stimulating Factors ... 1, 2025* Last Revised: Apr. 15, 2025 Replaces: N/A *Click here to view the current policy. ...
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: Apr. 1, 2025 Last Revised: Mar. 24, 2025 Replaces: ...
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/5.01.611.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/5.01.625.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/5.01.636.pdf#search=policy
PHARMACY POLICY - 5.01.636 Chronic Hepatitis B Antiviral Therapy Effective Date: Mar. 1, ... 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: Jul. 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, 2025 Last Revised: Feb. 10, 2025 ...
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, 2025 ...
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/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: Apr. 1, 2025 Last Revised: Mar. 10, ...
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: Jun. 1, 2025 Last Revised: May 12, 2025 ...
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/2.01.106.pdf#search=policy
MEDICAL POLICY - 2.01.106 Percutaneous Electrical Nerve Field Stimulation for Irritable Bowel Syndrome BCBSA Ref. Policy: 2.01.106 Effective Date: Nov. 1, 2024 Last Revised: Oct. ...
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: Jun. ...