• 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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350 results found for policy
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8.01.529 Hematopoietic Cell Transplantation for Non-Hodgkin Lymphomas
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: April 1, 2022 Last Revised: Oct. 1, 2022 ...
8.01.61 Focal Treatments for Prostate Cancer
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 ...
9.02.501 Orthognathic Surgery
https://www.premera.com/medicalpolicies/9.02.501.pdf#search=policy
MEDICAL POLICY - 9.02.501 Orthognathic Surgery Effective Date: Sept. 1, 2022 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
9.03.513 Treatment of Dry Eye Syndrome
https://www.premera.com/medicalpolicies/9.03.513.pdf#search=policy
MEDICAL POLICY - 9.03.513 Treatment of Dry Eye Syndrome BCBSA Ref. Policy: 9.03.29 Effective Date: June 1, 2022 Last Revised: Mar. 1, 2023 Replaces: N/A RELATED MEDICAL POLICIES: ...
1.01.30 Artificial Pancreas Device Systems
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: Sept. 1, 2022 Last Revised: Aug. 22, 2022 Replaces: N/A RELATED MEDICAL ...
13.01.500 Prescription Digital Therapeutics
https://www.premera.com/medicalpolicies/13.01.500.pdf#search=policy
MEDICAL POLICY - 13.01.500 Prescription Digital Therapeutics Effective Date: Jan. 1, 2023 ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
2.01.535 Temporomandibular Joint Disorder
https://www.premera.com/medicalpolicies/2.01.535.pdf#search=policy
MEDICAL POLICY - 2.01.535 Temporomandibular Joint Disorder BCBSA Ref. Policy: 2.01.21, 5.01.05 Effective Date: May 1, 2022 Last Revised: Nov. 1, 2022 Replaces: 2.01.21 RELATED ...
2.01.71 Nonpharmacologic Treatment of Rosacea
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 ...
2.01.91 Peroral Endoscopic Myotomy for Treatment of Esophageal...
https://www.premera.com/medicalpolicies/2.01.91.pdf#search=policy
MEDICAL POLICY - 2.01.91 Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia BCBSA Ref. Policy: 2.01.91 Effective Date: Feb. 1, 2023 Last Revised: Jan. 9, 2023 ...
3.01.510 Applied Behavior Analysis (ABA)
https://www.premera.com/medicalpolicies/3.01.510.pdf#search=policy
MEDICAL POLICY - 3.01.510 Applied Behavior Analysis (ABA) Effective Date: Jan. 1, 2023* Last Revised: Dec. 12, 2022 Replaces: N/A *This policy has been updated. View upcoming changes ...
5.01.512 Botulinum Toxins
https://www.premera.com/medicalpolicies/5.01.512.pdf#search=policy
MEDICAL POLICY - 5.01.512 Botulinum Toxins Effective Date: Mar. 1, 2023 Last Revised: ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | APPENDIX | ...
5.01.533 mTOR Kinase Inhibitors
https://www.premera.com/medicalpolicies/5.01.533.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.533 mTOR Kinase Inhibitors Effective Date: Nov. 1, 2022 ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
5.01.538 ALK Tyrosine Kinase Inhibitors
https://www.premera.com/medicalpolicies/5.01.538.pdf#search=policy
PHARMACY POLICY - 5.01.538 ALK Tyrosine Kinase Inhibitors Effective Date: Oct. 1, 2022 ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
5.01.544 Prostate Cancer Targeted Therapies
https://www.premera.com/medicalpolicies/5.01.544.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.544 Prostate Cancer Targeted Therapies Effective Date: ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
5.01.553 Myalept® (metreleptin)
https://www.premera.com/medicalpolicies/5.01.553.pdf#search=policy
PHARMACY POLICY - 5.01.553 Myalept ® (metreleptin) Effective Date: Oct. 1, 2022 Last ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
5.01.561 Repository Corticotropin Injection
https://www.premera.com/medicalpolicies/5.01.561.pdf#search=policy
MEDICAL POLICY - 5.01.561 Repository Corticotropin Injection BCBSA Ref. Policy: 5.01.17 Effective Date: Dec. 1, 2022 Last Revised: Nov. 21, 2022 Replaces: 5.01.17 RELATED MEDICAL ...
5.01.563 Pharmacotherapy of Inflammatory Bowel Disorder
https://www.premera.com/medicalpolicies/5.01.563.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.563 Pharmacotherapy of Inflammatory Bowel Disorder ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
6.01.525 Therapeutic Radiopharmaceuticals in Oncology
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: Dec. 1, 2022 Last Revised: Nov. 7, 2022 Replaces: ...
7.01.557 Gender Transition/Affirmation Surgery and Related Services
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 ...
7.01.564 Pulsed Radiofrequency
https://www.premera.com/medicalpolicies/7.01.564.pdf#search=policy
MEDICAL POLICY - 7.01.564 Pulsed Radiofrequency Effective Date: Sept. 1, 2022 Last ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
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