• 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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370 results found for policy
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7.01.589 Artificial Intervertebral Disc: Lumbar Spine
https://www.premera.com/medicalpolicies/7.01.589.pdf#search=policy
MEDICAL POLICY - 7.01.589 Artificial Intervertebral Disc: Lumbar Spine BCBSA Ref. Policy: 7.01.87 Effective Date: Feb. 1, 2024 Last Revised: Jan. 9, 2024 Replaces: 7.01.87 RELATED ...
8.01.25 Hematopoietic Cell Transplantation for Autoimmune Diseases
https://www.premera.com/medicalpolicies/8.01.25.pdf#search=policy
MEDICAL POLICY - 8.01.25 Hematopoietic Cell Transplantation for Autoimmune Diseases BCBSA Ref. Policy: 8.01.25 Effective Date: April 1, 2024 Last Revised: Mar. 25, 2024 Replaces: ...
8.01.29 Hematopoietic Cell Transplantation for Hodgkin Lymphoma
https://www.premera.com/medicalpolicies/8.01.29.pdf#search=policy
MEDICAL POLICY - 8.01.29 Hematopoietic Cell Transplantation for Hodgkin Lymphoma BCBSA Ref. Policy: 8.01.29 Effective Date: April 1, 2024 Last Revised: Mar. 25, 2024 Replaces: N/A ...
8.03.09 Vertebral Axial Decompression
https://www.premera.com/medicalpolicies/8.03.09.pdf#search=policy
MEDICAL POLICY - 8.03.09 Vertebral Axial Decompression BCBSA Ref. Policy: 8.03.09 Effective Date: July 1, 2023 Last Revised: June 26, 2023 Replaces: N/A RELATED MEDICAL POLICIES: ...
8.03.503 Occupational Therapy
https://www.premera.com/medicalpolicies/8.03.503.pdf#search=policy
MEDICAL POLICY - 8.03.503 Occupational Therapy Effective Date: Mar. 1, 2024 Last Revised: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
1.01.501 Wheelchairs (Manual or Motorized)
https://www.premera.com/medicalpolicies/1.01.501.pdf#search=policy
MEDICAL POLICY - 1.01.501 Wheelchairs (Manual or Motorized) Effective Date: Mar. 1, 2024 ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
2.01.38 Transesophageal Endoscopic Therapies for Gastroesophageal...
https://www.premera.com/medicalpolicies/2.01.38.pdf#search=policy
MEDICAL POLICY - 2.01.38 Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease BCBSA Ref. Policy: 2.01.38 Effective Date: Mar. 1, 2024 Last Revised: Feb. 12, ...
2.01.534 Intra-Articular Hyaluronan Injections for Osteoarthritis
https://www.premera.com/medicalpolicies/2.01.534.pdf#search=policy
MEDICAL POLICY - 2.01.534 Intra-Articular Hyaluronan Injections for Osteoarthritis BCBSA Ref. Policy: 2.01.31 Effective Date: July 1, 2023 Last Revised: June 12, 2023 Replaces: N/...
2.03.502 Monoclonal Antibodies for the Treatment of Lymphoma
https://www.premera.com/medicalpolicies/2.03.502.pdf#search=policy
MEDICAL POLICY - 2.03.502 Monoclonal Antibodies for the Treatment of Lymphoma BCBSA Ref. Policy: 2.03.05 Effective Date: April 4, 2024 Last Revised: Dec. 12, 2023 Replaces: N/A ...
5.01.503 Migraine and Cluster Headache Medications
https://www.premera.com/medicalpolicies/5.01.503.pdf#search=policy
PHARMACY POLICY - 5.01.503 Migraine and Cluster Headache Medications Effective Date: Oct. ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | APPENDIX | ...
5.01.540 Miscellaneous Oncology Drugs
https://www.premera.com/medicalpolicies/5.01.540.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.540 Miscellaneous Oncology Drugs Effective Date: Mar. 1, ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
5.01.550 Pharmacotherapy of Arthropathies
https://www.premera.com/medicalpolicies/5.01.550.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.550 Pharmacotherapy of Arthropathies Effective Date: ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
5.01.606 Hepatitis C Antiviral Therapy
https://www.premera.com/medicalpolicies/5.01.606.pdf#search=policy
PHARMACY POLICY - 5.01.606 Hepatitis C Antiviral Therapy Effective Date: Nov. 1, 2023 ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
7.01.109 Magnetic Resonance Imaging-Guided Focused Ultrasound
https://www.premera.com/medicalpolicies/7.01.109.pdf#search=policy
MEDICAL POLICY - 7.01.109 Magnetic Resonance Imaging-Guided Focused Ultrasound BCBSA Ref. Policy: 7.01.109 Effective Date: Oct. 1, 2023 Last Revised: Sept. 11, 2023 Replaces: N/A ...
7.01.18 Automated Percutaneous and Percutaneous Endoscopic Discectomy
https://www.premera.com/medicalpolicies/7.01.18.pdf#search=policy
MEDICAL POLICY - 7.01.18 Automated Percutaneous and Percutaneous Endoscopic Discectomy BCBSA Ref. Policy: 7.01.18 Effective Date: Sept. 1, 2023 Last Revised: Aug. 21, 2023 ...
7.01.523 Panniculectomy and Excision of Redundant Skin
https://www.premera.com/medicalpolicies/7.01.523.pdf#search=policy
MEDICAL POLICY - 7.01.523 Panniculectomy and Excision of Redundant Skin Effective Date: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
7.01.542 Lumbar Spinal Fusion in Adults
https://www.premera.com/medicalpolicies/7.01.542.pdf#search=policy
MEDICAL POLICY - 7.01.542 Lumbar Spinal Fusion in Adults BCBSA Ref. Policy: 7.01.141 Effective Date: Mar. 1, 2024 Last Revised: Feb. 12, 2024 Replaces: 7.01.141 RELATED MEDICAL ...
7.03.509 Liver Transplant and Combined Liver-Kidney Transplant
https://www.premera.com/medicalpolicies/7.03.509.pdf#search=policy
MEDICAL POLICY - 7.03.509 Liver Transplant and Combined Liver-Kidney Transplant BCBSA Ref. Policy: 7.03.06 Effective Date: Nov. 1, 2023 Last Revised: Oct. 9, 2023 Replaces: N/A ...
8.01.23 Hematopoietic Cell Transplantation for Epithelial Ovarian...
https://www.premera.com/medicalpolicies/8.01.23.pdf#search=policy
MEDICAL POLICY - 8.01.23 Hematopoietic Cell Transplantation for Epithelial Ovarian Cancer BCBSA Ref. Policy: 8.01.23 Effective Date: April 1, 2024 Last Revised: Mar. 11, 2024 ...
8.01.26 Hematopoietic Cell Transplantation for Acute Myeloid...
https://www.premera.com/medicalpolicies/8.01.26.pdf#search=policy
MEDICAL POLICY - 8.01.26 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia BCBSA Ref. Policy: 8.01.26 Effective Date: April 1, 2024 Last Revised: Mar. 25, 2024 ...
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