• 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/5.01.575.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.575 Dupixent (dupilumab) Effective Date: June 1, 2024 ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.638.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.638 Omisirge (Omidubicel) Effective Date: Sept. 1, 2023 ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/7.01.144.pdf#search=policy
MEDICAL POLICY - 7.01.144 Patient-Specific Instrumentation (e.g., Cutting Guides) for Joint Arthroplasty BCBSA Ref. Policy: 7.01.144 Effective Date: July 1, 2023 Last Revised: ...
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, 2023 ...
https://www.premera.com/medicalpolicies/1.03.04.pdf#search=policy
MEDICAL POLICY - 1.03.04 Powered Exoskeleton for Ambulation in Patients With Lower-Limb Disabilities BCBSA Ref. Policy: 1.03.04 Effective Date: June 1, 2024 Last Revised: May 13, ...
https://www.premera.com/medicalpolicies/2.02.24.pdf#search=policy
MEDICAL POLICY - 2.02.24 Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting BCBSA Ref. Policy: 2.02.24 Effective Date: Sept. 1, 2023 Last ...
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: Sept. 1, ...
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, 2024 Last Revised: April 8, ...
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, 2024 Last Revised: Dec. 26, ...
https://www.premera.com/medicalpolicies/5.01.42.pdf#search=policy
MEDICAL POLICY - 5.01.42 Gene Therapies for Thalassemia BCBSA Ref. Policy: 5.01.42 Effective Date: June 1, 2024 Last Revised: May 14, 2024 Replaces: N/A RELATED MEDICAL POLICIES: ...
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/5.01.627.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.627 Thymic Stromal Lymphopoietin (TSLP) Inhibitors ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.633.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.633 Intraarticular Corticosteroids Effective Date: Sept. ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.632.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.632 Adstiladrin® (nadofaragene firadenovec-vncg) ... 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: June 1, ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/7.01.147.pdf#search=policy
MEDICAL POLICY - 7.01.147 Minimally Invasive Ablation Procedures for Morton and Other Peripheral Neuromas BCBSA Ref. Policy: 7.01.147 Effective Date: Sept. 1, 2023 Last Revised: ...
https://www.premera.com/medicalpolicies/7.01.78.pdf#search=policy
MEDICAL POLICY - 7.01.78 Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions BCBSA Ref. Policy: 7.01.78 Effective Date: July 1, 2023 Last Revised: June ...
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, 2023 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, 2023 Last Revised: Sept. ...
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: Aug. 1, 2023 Last Revised: May ...