• 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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406 results found for policy
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. ...
https://www.premera.com/medicalpolicies/2.01.91.pdf#search=policy
MEDICAL POLICY - 2.01.91 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia and Gastroparesis BCBSA Ref. Policy: 2.01.91 Effective Date: Feb. 1, 2025 Last Revised: ...
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/2.04.152.pdf#search=policy
MEDICAL POLICY - 2.04.152 Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes BCBSA Ref. Policy: 2.04.152 Effective Date: May 1, 2025 Last Revised: Apr. 7, 2025 ...
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/5.01.569.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.569 Pharmacotherapy of Type 1 and Type 2 Diabetes ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
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/5.01.636.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/5.01.640.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.640 Pharmacologic Treatment of Sickle Cell Disease BCBSA Ref. Policy: 5.01.48 Effective Date: May 1, 2025* Last Revised: Apr. 8, 2025 Replaces: N/...
https://www.premera.com/medicalpolicies/5.01.641.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.641 Pharmacologic Treatment of Vitiligo Effective Date: ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.644.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.644 Medical Pharmacologic Treatment of Multiple Sclerosis Effective Date: Feb. 1, 2025* Last Revised: Apr. 1, 2025 Replaces: N/A *This policy has ...
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, 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/5.01.559_2025-10-03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.559 IL-5 Inhibitors Effective Date: Oct. 3, 2025* Last Revised: Jun. 10, 2025 Replaces: N/A *This policy has been revised. Click here to view the ...
https://www.premera.com/medicalpolicies/5.01.570_2025-10-03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.570 Pharmacologic Treatment of Duchenne Muscular Dystrophy BCBSA Ref. Policy: 5.01.27 Effective Date: Oct. 3, 2025* Last Revised: Jun. 10, 2025 ...