• 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/2.02.516.pdf#search=policy
MEDICAL POLICY - 2.02.516 Catheter Ablation as Treatment for Atrial Fibrillation BCBSA Ref. Policy: 2.02.19 Effective Date: July 3, 2025* Last Revised: May 13, 2025 Replaces: N/A ...
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/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/5.01.629_2025-07-01.pdf#search=policy
/ MEDICAL POLICY - 5.01.629 Pharmacologic Treatment of Psoriasis Effective Date: July 1, 2025* Last Revised: Apr. 8, 2025 Replaces: N/A *Click here to view the current policy. ...
https://www.premera.com/medicalpolicies/5.01.633.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.633 Intraarticular Corticosteroids Effective Date: May ... 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 BCBSA Ref. Policy: 5.01.48 Effective Date: May 1, 2025 Last Revised: Apr. 8, 2025 Replaces: N/A ...
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 ... Medical Necessity criteria within this policy DOES NOT apply to Alaska fully- insured ...
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/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: Jun. 1, 2025 Last Revised: May 12, ...
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/2.04.521.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: April 1, 2025 Replaces: N/A RELATED ...
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/5.01.588.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.588 Pharmacologic Prevention and Treatment of HIV/AIDS ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
https://www.premera.com/medicalpolicies/5.01.632.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.632 Pharmacologic Treatment of Bladder Cancer Effective ... 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: Apr. 1, 2025 Last Revised: Mar. 10, 2025 ...
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, 2025 Last Revised: Dec. 9, 2024 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/7.01.174.pdf#search=policy
PHARMACY / MEDICAL POLICY - 7.01.174 Stationary Ultrasonic Diathermy Devices BCBSA Ref. Policy: 7.01.174 Effective Date: Apr. 1, 2025 Last Revised: Mar. 10, 2025 Replaces: N/A ...
https://www.premera.com/medicalpolicies/7.01.175.pdf#search=policy
MEDICAL POLICY - 7.01.175 Temporarily Implanted Nitinol Device (iTind) for Benign Prostatic Hyperplasia BCBSA Ref. Policy: 7.01.175 Effective Date: Mar. 1, 2025 Last Revised: Feb. ...