• 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.

    Enter one or more keywords. Enter "policy" to see a complete list of policies.

* One or more keywords are required

  Reset search
382 results found for policy
https://www.premera.com/medicalpolicies/5.01.533.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.533 mTOR Kinase Inhibitors Effective Date: Apr. 1, 2025 ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/5.01.552.pdf#search=policy
PHARMACY POLICY - 5.01.552 Hetlioz (tasimelteon) Effective Date: Mar. 1, 2025 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.559.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.559 IL-5 Inhibitors Effective Date: Apr. 1, 2025 Last ... Medical Necessity criteria within this policy DOES NOT apply to Alaska fully- insured ...
https://www.premera.com/medicalpolicies/5.01.563_2025-07-01.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.563 Pharmacotherapy of Inflammatory Bowel Disorder ... Apr. 8, 2025 Replaces: Extracted from 5.01.550 *Click here to view the current policy. ...
https://www.premera.com/medicalpolicies/5.01.587.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.587 Hereditary Angioedema Effective Date: Feb. 1, 2025 ... Medical Necessity criteria within this policy DOES NOT apply to Alaska fully- insured ...
https://www.premera.com/medicalpolicies/5.01.591.pdf#search=policy
MEDICAL POLICY - 5.01.591 Immune Checkpoint Inhibitors Effective Date: May 1, 2025 Last ... Medical Necessity criteria within this policy DOES NOT apply to Alaska fully- insured ...
https://www.premera.com/medicalpolicies/5.01.605_2025-09-05.pdf#search=policy
Necessity Criteria for Pharmacy Edits Effective Date: Sep. 5, 2025* Last Revised: May 13, 2025 Replaces: N/A *This policy has been revised. Click here to view the current policy. ...
https://www.premera.com/medicalpolicies/5.01.648.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.648 Insulin Therapy Effective Date: May 1, 2025 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
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, 2024 Last Revised: Nov. 11, 2024 Replaces: N/A RELATED MEDICAL POLICIES: ...
https://www.premera.com/medicalpolicies/6.01.525.pdf#search=policy
MEDICAL / PHARMACY POLICY - 6.01.525 Therapeutic Radiopharmaceuticals in Oncology BCBSA Ref. Policy: 6.01.60 & 5.01.43 Effective Date: May 1, 2025 Last Revised: Apr. 21, 2025 ...
https://www.premera.com/medicalpolicies/6.01.527.pdf#search=policy
MEDICAL POLICY - 6.01.527 Diagnosis and Treatment of Sacroiliac Joint Pain BCBSA Ref. Policy: 6.01.23 Effective Date: Feb. 1, 2025 Last Revised: Jan. 13, 2025 Replaces: 6.01.524 ...
https://www.premera.com/medicalpolicies/7.01.139.pdf#search=policy
MEDICAL POLICY - 7.01.139 Peripheral Subcutaneous Field Stimulation BCBSA Ref. Policy: 7.01.139 Effective Date: July 1, 2024 Last Revised: Jan. 1, 2025 Replaces: N/A RELATED ...
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, 2024 Last Revised June 24, 2024 Replaces: 7.01.25 ...
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/7.01.72.pdf#search=policy
POLICY - 7.01.72 Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty, and Intraosseous Basivertebral Nerve Ablation BCBSA Ref. Policy: ...
https://www.premera.com/medicalpolicies/7.03.04.pdf#search=policy
MEDICAL POLICY - 7.03.04 Isolated Small Bowel Transplant BCBSA Ref. Policy: 7.03.04 Effective Date: Nov. 1, 2024 Last Revised: Oct. 7, 2024 Replaces: 7.03.511 RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/7.03.12.pdf#search=policy
MEDICAL POLICY - 7.03.12 Islet Transplantation for Chronic Pancreatitis and Donislecel-jujn for Type 1 Diabetes BCBSA Ref. Policy: 7.03.12 Effective Date: Jan. 1, 2025 Last ...
https://www.premera.com/medicalpolicies/8.01.540.pdf#search=policy
MEDICAL POLICY - 8.01.540 Cranial Electrotherapy Stimulation and Auricular Electrostimulation BCBSA Ref. Policy: 8.01.58 Effective Date: May 1, 2025 Last Revised: Apr. 7, 2025 ...
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, 2024 Last Revised: Nov. 11, 2024 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/9.02.501.pdf#search=policy
MEDICAL POLICY - 9.02.501 Orthognathic Surgery Effective Date: Nov. 1, 2024 Last Revised: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...