• 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/5.01.584_2025-10-03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.584 CGRP Inhibitors for Migraine Prophylaxis BCBSA Ref. Policy: 5.01.29 Effective Date: Oct. 3, 2025* Last Revised: Jun. 10, 2025 Replaces: N/A ...
https://www.premera.com/medicalpolicies/5.01.652.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.652 Miscellaneous Pharmacologic Treatments of Psoriasis ... Medical Necessity criteria within this policy DOES NOT apply to Alaska fully- insured ...
https://www.premera.com/medicalpolicies/2.01.100.pdf#search=policy
MEDICAL POLICY - 2.01.100 Dry Needling of Trigger Points for Myofascial Pain BCBSA Ref. Policy: 2.01.100 Effective Date: Jul. 1, 2025 Last Revised: Jun. 9, 2025 Replaces: N/A ...
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/2.04.125.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/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/5.01.633.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/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/5.01.571_2025-10-03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.571 C3 and C5 Complement Inhibitors BCBSA Ref. Policy: 5.01.39 Effective Date: Oct. 3, 2025* Last Revised: Jun. 10, 2025 Replaces: N/A *View the ...
https://www.premera.com/medicalpolicies/5.01.576_2025-10-03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.576 Drugs for Rare Diseases BCBSA Ref. Policy: 5.01.37 and 5.01.40 Effective Date: Oct. 3, 2025* Last Revised: Jun. 10, 2025 Replaces: N/A *This ...
https://www.premera.com/medicalpolicies/5.01.651_2025-10-03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.651 Pharmacologic Treatment of Parkinson's Disease Effective Date: Oct. 3, 2025* Last Revised: Jun. 10, 2025 Replaces: N/A *This policy has been ...
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: Jul. 1, 2025 Last Revised: Jun. 23, 2025 Replaces: ...
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/2.04.521.pdf#search=policy
MEDICAL POLICY - 2.04.521 Evaluation of Biomarkers for Alzheimer Disease BCBSA Ref. Policy: 2.04.14 Effective Date: Apr. 6, 2025 Last Revised: Jul. 1, 2025 Replaces: N/A RELATED ...
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/5.01.642.pdf#search=policy
MEDICAL POLICY - 5.01.642 Gene Therapies for Rare Diseases BCBSA Ref. Policy: 5.01.49 Effective Date: Mar. 1, 2025 Last Revised: Jul. 1, 2025 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/5.01.616_2025-10-03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.616 Pharmacologic Treatment of Gout Effective Date: Oct. ... Medical Necessity criteria within this policy DOES NOT apply to Alaska fully- insured ...
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: Jul. 1, 2025 Last Revised: ...