• 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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382 results found for policy
https://www.premera.com/medicalpolicies/1.01.525.pdf#search=policy
MEDICAL POLICY - 1.01.525 Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis BCBSA Ref. Policy: 1.01.28 Effective Date: Jun. 1, 2025 Last ...
https://www.premera.com/medicalpolicies/10.01.533.pdf#search=policy
MEDICAL POLICY - 10.01.533 Non-covered Experimental/Investigational Services Effective ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
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: Feb. 1, 2025 Last Revised: Jan. 14, 2025 Replaces: N/A RELATED MEDICAL ...
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, 2025 Last Revised: Apr. 7, 2025 Replaces: 2.01.21 RELATED ...
https://www.premera.com/medicalpolicies/2.02.515.pdf#search=policy
MEDICAL POLICY - 2.02.515 Leadless Cardiac Pacemakers BCBSA Ref. Policy: 2.02.32 Effective Date: Aug. 1, 2024 Last Revised: July 8, 2024 Replaces: 2.02.32 RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/2.04.507.pdf#search=policy
MEDICAL POLICY - 2.04.507 Testing Serum Vitamin D Levels BCBSA Ref Policy: 2.04.135 Effective Date: Mar. 1, 2025 Last Revised: Feb. 24, 2025 Replaces: 2.04.135 RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/5.01.512.pdf#search=policy
MEDICAL POLICY - 5.01.512 Botulinum Toxins BCBSA Ref. Policy: 5.01.05 Effective Date: Apr. 1, 2025 Last Revised: Mar. 24, 2025 Replaces: N/A RELATED MEDICAL POLICIES: 2.01.535 ...
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/5.01.539.pdf#search=policy
PHARMACY POLICY - 5.01.539 Pharmacologic Treatment of Cystic Fibrosis Effective Date: May ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
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 ∞ ...
https://www.premera.com/medicalpolicies/5.01.553.pdf#search=policy
PHARMACY POLICY - 5.01.553 Myalept (metreleptin) Effective Date: May 1, 2025 Last ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.556.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.556 Rituximab: Non-oncologic and Miscellaneous Uses BCBSA Ref. Policy: 5.01.24 Effective Date: Feb. 1, 2025* Last Revised: Jan. 27, 2025 Replaces: ...
https://www.premera.com/medicalpolicies/5.01.558.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.558 Pharmacologic Treatment of High Cholesterol ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
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: Apr. 1, 2025 Last Revised: Mar. 24, 2025 Replaces: 5.01.17 RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/5.01.565.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.565 Pharmacotherapy of Multiple Sclerosis Effective ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.566.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.566 Pharmacotherapy of Thrombocytopenia Effective Date: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.612.pdf#search=policy
PHARMACY POLICY - 5.01.612 Pharmacologic Treatment of Cystinosis Effective Date: Mar. 1, ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
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: July 1, 2024 Last Revised: June 10, ...
https://www.premera.com/medicalpolicies/7.01.533.pdf#search=policy
.../Management of Breast Implants BCBSA Ref. Policy: 7.01.22 Effective Date: Sept. 1, 2024 ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | REFERENCES | ...
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 ...