• 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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371 results found for policy
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: April 1, 2024 Last Revised: Mar. 11, 2024 Replaces: N/A ...
https://www.premera.com/medicalpolicies/7.01.533.pdf#search=policy
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | REFERENCES | ... This policy describes when breast reconstruction is covered to address a medical ...
https://www.premera.com/medicalpolicies/11.01.523_2024-06-07.pdf#search=policy
Last Revised: March 12, 2024 Replaces: N/A *This policy has been updated. View the current version here. View the upcoming policy changes here for July 4, 2024. RELATED MEDICAL ...
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: August 2, 2024 Last Revised: April 9, 2024 Replaces: N/A ...
https://www.premera.com/medicalpolicies/5.01.605.pdf#search=policy
This policy describes coverage criteria for drugs in the plan's pharmacy prior ... section is for your general knowledge and is not to be taken as policy coverage criteria. ...
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: April 1, 2024 Last Revised: ...
https://www.premera.com/medicalpolicies/5.01.635.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.635 Pharmacologic Treatment of Epidermolysis Bullosa ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.560.pdf#search=policy
POLICIES: 10.01.511 Medical Policy and Clinical Guidelines: Definitions and Procedures Select a hyperlink below to be directed to that section. POLICY CRITERIA | DOCUMENTATION ...
https://www.premera.com/medicalpolicies/4.01.502.pdf#search=policy
MEDICAL POLICY - 4.01.502 Surgical Interruption of Pelvic Nerve Pathways for Chronic Pelvic Pain BCBSA Ref Policy: 4.01.17 Effective Date: Nov. 1, 2023 Last Revised: Oct. 23, 2023 ...
https://www.premera.com/medicalpolicies/5.01.626.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.626 Amyloid Antibodies for the Treatment of Alzheimer's Disease BCBSA Ref. Policy: 5.01.38 Effective Date: May 1, 2024 Last Revised: April 9, 2024 ...
https://www.premera.com/medicalpolicies/1.01.520.pdf#search=policy
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ... This policy describes when a hospital bed may be covered for use at home. Note: The ...
https://www.premera.com/medicalpolicies/2.01.107.pdf#search=policy
MEDICAL POLICY - 2.01.107 Fractional Carbon Dioxide (CO2) Laser Ablation Treatment of Hypertrophic Scars or Keloids for Functional Improvement BCBSA Ref. Policy: 2.01.107 Effective ...
https://www.premera.com/medicalpolicies/7.01.584.pdf#search=policy
MEDICAL POLICY - 7.01.584 Nerve Repair for Peripheral Nerve Injuries Using Synthetic ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/9.02.506.pdf#search=policy
below to be redirected to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ... This policy describes when dental restorations are covered. Cosmetic dental restorations ...
https://www.premera.com/medicalpolicies/10.01.523.pdf#search=policy
below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ... section is for your general knowledge and is not to be taken as policy coverage criteria. ...
https://www.premera.com/medicalpolicies/11.01.522.pdf#search=policy
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ... This policy describes skilled hourly care and outlines how the plan may cover these ...
https://www.premera.com/medicalpolicies/8.01.502.pdf#search=policy
Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to ...
https://www.premera.com/medicalpolicies/9.02.503.pdf#search=policy
POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ... In some cases, other imaging such as MRI or ultrasound, are needed. This policy explains ...
https://www.premera.com/medicalpolicies/5.01.637.pdf#search=policy
below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ... This policy describes when these drugs for alopecia may be considered medically necessary. ...
https://www.premera.com/medicalpolicies/10.01.517.pdf#search=policy
Policy and Clinical Guidelines: Definitions and Procedures 10.01.514 Cosmetic and Reconstructive Services Select a hyperlink below to be directed to that section. POLICY ...