• 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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408 results found for policy
https://www.premera.com/medicalpolicies/2.04.515.pdf#search=policy
MEDICAL POLICY - 2.04.515 Plasma-based Proteomic Screening in the Management of Pulmonary Nodules BCBSA Ref. Policy: 2.04.142 Effective Date: Aug. 1, 2024 Last Revised: July 8, ...
https://www.premera.com/medicalpolicies/5.01.586.pdf#search=policy
MEDICAL POLICY - 5.01.586 Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric or Substance Use Disorders BCBSA Ref. Policy: 5.01.16 Effective Date: Feb. 1, ...
https://www.premera.com/medicalpolicies/5.01.647.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.647 Medical Necessity Criteria for Custom Open and ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/6.01.68.pdf#search=policy
MEDICAL POLICY - 6.01.68 Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung BCBSA Ref. Policy: 6.01.68 Effective Date: Jan. 1, 2025 Last ...
https://www.premera.com/medicalpolicies/7.01.168.pdf#search=policy
MEDICAL POLICY - 7.01.168 Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis BCBSA Ref. Policy: 7.01.168 Effective Date: May 1, 2025 Last ...
https://www.premera.com/medicalpolicies/7.01.574.pdf#search=policy
MEDICAL POLICY - 7.01.574 Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain and Other Conditions BCBSA Ref. Policy 1.01.31, 7.01.29, 7.01.106 Effective ...
https://www.premera.com/medicalpolicies/7.01.597.pdf#search=policy
MEDICAL POLICY - 7.01.597 Radiofrequency Volumetric Tissue Reduction for Nasal Obstruction BCBSA Ref. Policy: 7.01.156 Effective Date: May 1, 2025 Last Revised: Apr. 8, 2025 ...
https://www.premera.com/medicalpolicies/5.01.640_2025-10-03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.640 Pharmacologic Treatment of Sickle Cell Disease BCBSA Ref. Policy: 5.01.48 Effective Date: Oct. 3, 2025* Last Revised: Jun. 10, 2025 Replaces: ...
https://www.premera.com/medicalpolicies/5.01.644_2025-10-03.pdf#search=policy
POLICY - 5.01.644 Medical Pharmacologic Treatment of Multiple Sclerosis Effective Date: Oct. 3, 2025* Last Revised: Jun. 10, 2025 Replaces: N/A *View the current policy here. ...
https://www.premera.com/medicalpolicies/11.01.523.pdf#search=policy
May 6, 2025* Last Revised: Jan. 27, 2025 Replaces: N/A *This policy has been revised. ... Medical Necessity criteria within this policy DOES NOT apply to Alaska fully- insured ...
https://www.premera.com/medicalpolicies/2.01.49.pdf#search=policy
MEDICAL POLICY - 2.01.49 Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hyperplasia BCBSA Ref. Policy: 2.01.49 ...
https://www.premera.com/medicalpolicies/2.04.26.pdf#search=policy
MEDICAL POLICY - 2.04.26 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis BCBSA Ref. Policy: 2.04.26 Effective Date: Mar. 1, 2025 Last Revised: Feb. 10, 2025 Replaces: N/A ...
https://www.premera.com/medicalpolicies/3.03.01.pdf#search=policy
PHARMACY / MEDICAL POLICY - 3.03.01 Prescription Digital Health Diagnostic Aid for Autism Spectrum Disorder BCBSA Ref. Policy: 3.03.01 Effective Date: Oct. 1, 2024 Last Revised: ...
https://www.premera.com/medicalpolicies/3.03.03.pdf#search=policy
PHARMACY / MEDICAL POLICY - 3.03.03 Prescription Digital Therapeutics for Attention Deficit/Hyperactivity Disorder BCBSA Ref. Policy: 3.03.03 Effective Date: Oct. 1, 2024 Last ...
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, 2025 Last Revised: Apr. 21, 2025 ...
https://www.premera.com/medicalpolicies/5.01.635.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.635 Pharmacologic Treatment of Epidermolysis Bullosa BCBSA Ref. Policy: 5.01.47 Effective Date: Mar. 1, 2025 Last Revised: Feb. 24, 2025 Replaces: ...
https://www.premera.com/medicalpolicies/7.01.172.pdf#search=policy
MEDICAL POLICY - 7.01.172 Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation BCBSA Ref. Policy: 7.01.172 Effective Date: Apr. 1, 2025 ...
https://www.premera.com/medicalpolicies/7.01.563.pdf#search=policy
MEDICAL POLICY - 7.01.563 Ablative Treatments for Occipital Neuralgia, Chronic Headaches, ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/7.01.587.pdf#search=policy
MEDICAL POLICY - 7.01.587 Open and Thoracoscopic Approaches to Treat Atrial Fibrillation and Atrial Flutter (Maze and Related Procedures) BCBSA Ref. Policy: 7.01.14 Effective Date: ...
https://www.premera.com/medicalpolicies/7.01.596.pdf#search=policy
MEDICAL POLICY - 7.01.596 Adjunctive Techniques for Screening, Surveillance, and Risk Classification of Barrett Esophagus and Esophageal Dysplasia BCBSA Ref. Policy: 7.01.167 ...