• 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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369 results found for policy
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, 2024 Last Revised: Dec. 11, 2023 ...
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/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: April 1, 2024 Last Revised: Mar. 25, ...
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, 2023 Last Revised: Aug. 21, 2023 ...
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, 2024 Last Revised: Jan. 8, 2024 ...
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/5.01.569.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/5.01.574.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/5.01.640.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.640 Pharmacologic Treatment of Sickle Cell Disease ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/7.01.153.pdf#search=policy
MEDICAL POLICY - 7.01.153 Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast BCBSA Ref. Policy: 7.01.153 Effective Date: Mar. 1, 2024 Last Revised: Feb. 26, 2024 ...
https://www.premera.com/medicalpolicies/7.01.171.pdf#search=policy
MEDICAL POLICY - 7.01.171 Remote Electrical Neuromodulation for Migraines BCBSA Ref. Policy: 7.01.171 Effective Date: Jan. 1, 2024 Last Revised: Dec. 11, 2023 Replaces: N/A ...
https://www.premera.com/medicalpolicies/9.03.508.pdf#search=policy
MEDICAL POLICY - 9.03.508 Orthoptic Training for the Treatment of Vision or Learning Disabilities BCBSA Ref. Policy: 9.03.03 Effective Date: June 1, 2024 Last Revised: May 13, ...
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, 2024 Last Revised: May 13, 2024 Replaces: ...
https://www.premera.com/medicalpolicies/4.02.06.pdf#search=policy
MEDICAL POLICY - 4.02.06 Uterus Transplantation for Absolute Uterine Factor Infertility BCBSA Ref. Policy: 4.02.06 Effective Date: Nov. 1, 2023 Last Revised: Oct. 9, 2023 ...
https://www.premera.com/medicalpolicies/5.01.565_2024-07-04.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.565 Pharmacotherapy of Multiple Sclerosis Effective Date: July 4, 2024 Last Revised: Mar. 12, 2024 Replaces: Extracted from 5.01.550 *This policy ...
https://www.premera.com/medicalpolicies/5.01.571_2024-08-02.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.571 C3 and C5 Complement Inhibitors Effective Date: Aug. 2, 2024* Last Revised: April 9, 2024 Replaces: N/A *View the current policy here. RELATED ...