• 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/2.04.73.pdf#search=policy
MEDICAL POLICY - 2.04.73 Intracellular Micronutrient Analysis BCBSA Ref. Policy: 2.04.73 Effective Date: Feb. 1, 2023 Last Revised: Jan. 23, 2023 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/5.01.517.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.517 Use of Vascular Endothelial Growth Factor Receptor ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.536.pdf#search=policy
MEDICAL POLICY - 5.01.536 Nulojix® (belatacept) for Adults Effective Date: May 1, 2023 ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.538.pdf#search=policy
PHARMACY POLICY - 5.01.538 ALK Tyrosine Kinase Inhibitors Effective Date: Sept. 1, 2023 ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/6.01.521.pdf#search=policy
MEDICAL POLICY - 6.01.521 Bone Mineral Density Studies BCBSA Ref Policy: 6.01.01 Effective Date: Dec. 1, 2022 Last Revised: Nov. 7, 2022 Replaces: N/A RELATED MEDICAL POLICIES: ...
https://www.premera.com/medicalpolicies/6.01.525.pdf#search=policy
MEDICAL POLICY - 6.01.525 Therapeutic Radiopharmaceuticals in Oncology BCBSA Ref. Policy: 6.01.60 & 5.01.43 Effective Date: Oct. 1, 2023 Last Revised: Sept. 25, 2023 Replaces: ...
https://www.premera.com/medicalpolicies/7.01.546.pdf#search=policy
MEDICAL POLICY - 7.01.546 Spinal Cord and Dorsal Root Ganglion Stimulation BCBSA Ref. Policy: 7.01.25 Effective Date: July 1, 2023 Last Revised June 12, 2023 Replaces: 7.01.25 ...
https://www.premera.com/medicalpolicies/7.03.08.pdf#search=policy
MEDICAL POLICY - 7.03.08 Heart/Lung Transplant BCBSA Ref. Policy: 7.03.08 Effective Date: Nov. 1, 2023 Last Revised: Oct. 9, 2023 Replaces: Extracted from 7.03.509 RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/7.03.02.pdf#search=policy
MEDICAL POLICY - 7.03.02 Allogeneic Pancreas Transplant BCBSA Ref. Policy: 7.03.02 Effective Date: Nov. 1, 2023 Last Revised: Oct. 9, 2023 Replaces: Extracted from 7.03.509 ...
https://www.premera.com/medicalpolicies/7.01.557.pdf#search=policy
MEDICAL POLICY - 7.01.557 Gender Transition/Affirmation Surgery and Related Services ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/7.01.560.pdf#search=policy
MEDICAL POLICY - 7.01.560 Cervical Spine Surgeries: Discectomy, Laminectomy, and Fusion ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/8.01.529.pdf#search=policy
MEDICAL POLICY - 8.01.529 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas BCBSA Ref. Policy: 8.01.20 Effective Date: May 1, 2023 Last Revised: Apr. 11, 2023 Replaces: ...
https://www.premera.com/medicalpolicies/8.01.58.pdf#search=policy
MEDICAL POLICY - 8.01.58 Cranial Electrotherapy Stimulation and Auricular Electrostimulation BCBSA Ref. Policy: 8.01.58 Effective Date: May 1, 2023 Last Revised: Oct. 4, 2023 ...
https://www.premera.com/medicalpolicies/9.02.501.pdf#search=policy
MEDICAL POLICY - 9.02.501 Orthognathic Surgery Effective Date: Sept. 1, 2023 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/7.01.48.pdf#search=policy
MEDICAL POLICY - 7.01.48 Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions BCBSA Ref. Policy: 7.01.48 Effective Date: Aug. 1, 2023 Last Revised: July 11, ...
https://www.premera.com/medicalpolicies/8.01.61.pdf#search=policy
MEDICAL POLICY - 8.01.61 Focal Treatments for Prostate Cancer BCBSA Ref. Policy: 8.01.61 Effective Date: Dec. 1, 2022 Last Revised: Jan. 1, 2023 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/1.01.30.pdf#search=policy
MEDICAL POLICY - 1.01.30 Artificial Pancreas Device Systems BCBSA Ref. Policy: 1.01.30 Effective Date: Oct. 1, 2023 Last Revised: Sept. 12, 2023 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/13.01.500.pdf#search=policy
MEDICAL POLICY - 13.01.500 Prescription Digital Therapeutics BCBSA Ref. Policy: 3.03.02 Effective Date: Nov. 1, 2023 Last Revised: Oct. 10, 2023 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/5.01.563.pdf#search=policy
POLICY - 5.01.563 Pharmacotherapy of Inflammatory Bowel Disorder Effective Date: Sept. 1, 2023* Last Revised: Aug. 8, 2023 Replaces: Extracted from 5.01.550 *This policy has been ...
https://www.premera.com/medicalpolicies/2.01.71.pdf#search=policy
MEDICAL POLICY - 2.01.71 Nonpharmacologic Treatment of Rosacea BCBSA Ref. Policy: 2.01.71 Effective Date: Feb. 1, 2023 Last Revised: Jan. 23, 2023 Replaces: 2.01.519 RELATED ...