• 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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7.01.83 Auditory Brainstem Implant
https://www.premera.com/medicalpolicies/7.01.83.pdf#search=policy
MEDICAL POLICY - 7.01.83 Auditory Brainstem Implant BCBSA Ref. Policy: 7.01.83 Effective Date: May 1, 2022 Last Revised: April 11, 2022 Replaces: N/A RELATED MEDICAL POLICIES: ...
7.03.02 Allogeneic Pancreas Transplant
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, 7.03.14 Effective Date: Nov. 1, 2022 Last Revised: Oct. 10, 2022 Replaces: Extracted from ...
7.03.07 Lung and Lobar Lung Transplant
https://www.premera.com/medicalpolicies/7.03.07.pdf#search=policy
MEDICAL POLICY - 7.03.07 Lung and Lobar Lung Transplant BCBSA Ref. Policy: 7.03.07, 7.03.14 Effective Date: Nov. 1, 2022 Last Revised: Oct. 10, 2022 Replaces: Extracted from ...
7.03.08 Heart/Lung Transplant
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, 7.03.14 Effective Date: Nov. 1, 2022 Last Revised: Oct. 10, 2022 Replaces: Extracted from 7.03.509 ...
8.01.531 Hematopoietic Cell Transplantation for Waldenström...
https://www.premera.com/medicalpolicies/8.01.531.pdf#search=policy
MEDICAL POLICY - 8.01.531 Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia BCBSA Ref. Policy: 8.01.54 Effective Date: Dec. 1, 2022 Last Revised: Nov. 7, 2022 ...
8.01.58 Cranial Electrotherapy Stimulation and Auricular Electrostimul...
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, 2022 Last Revised: Jan. 1, 2023 ...
10.01.520 Review for Coverage in the Absence of a Medical Policy...
https://www.premera.com/medicalpolicies/10.01.520.pdf#search=policy
BENEFIT COVERAGE GUIDELINE - 10.01.520 Review for Coverage in the Absence of a Medical Policy, Pharmacy Policy, or Utilization Management Guideline Effective Date: Apr. 1, 2022 ...
2.01.98 Orthopedic Applications of Platelet-Rich Plasma
https://www.premera.com/medicalpolicies/2.01.98.pdf#search=policy
MEDICAL POLICY - 2.01.98 Orthopedic Applications of Platelet-Rich Plasma BCBSA Ref. Policy: 2.01.98 Effective Date: July 1, 2022 Last Revised: June 13, 2022 Replaces: N/A RELATED ...
2.02.09 Closure Devices for Patent Foramen Ovale and Atrial Septal...
https://www.premera.com/medicalpolicies/2.02.09.pdf#search=policy
MEDICAL POLICY - 2.02.09 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects BCBSA Ref. Policy: 2.02.09 Effective Date: Aug. 1, 2022 Last Revised: July 11, 2022 ...
2.02.32 Leadless Cardiac Pacemakers
https://www.premera.com/medicalpolicies/2.02.32.pdf#search=policy
MEDICAL POLICY - 2.02.32 Leadless Cardiac Pacemakers BCBSA Ref. Policy: 2.02.32 Effective Date: Aug. 1, 2022 Last Revised: July 12, 2022 Replaces: N/A RELATED MEDICAL POLICIES: ...
2.03.07 Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for...
https://www.premera.com/medicalpolicies/2.03.07.pdf#search=policy
MEDICAL POLICY - 2.03.07 Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Select Intra-Abdominal and Pelvic Malignancies BCBSA Ref. Policy: 2.03.07 Effective Date: Oct. 1, ...
2.04.144 Gene Therapy for Inherited Retinal Dystrophy
https://www.premera.com/medicalpolicies/2.04.144.pdf#search=policy
MEDICAL POLICY - 2.04.144 Gene Therapy for Inherited Retinal Dystrophy BCBSA Ref. Policy: 2.04.144 Effective Date: Apr. 1, 2022 Last Revised: Mar. 7, 2022 Replaces: 8.01.536 ...
2.04.62 Multimarker Serum Testing Related to Ovarian Cancer
https://www.premera.com/medicalpolicies/2.04.62.pdf#search=policy
MEDICAL POLICY - 2.04.62 Multimarker Serum Testing Related to Ovarian Cancer BCBSA Ref. Policy: 2.04.62 Effective Date: Feb. 1, 2023 Last Revised: Jan. 23, 2023 Replaces: N/A ...
5.01.559 IL-5 Inhibitors
https://www.premera.com/medicalpolicies/5.01.559.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.559 IL-5 Inhibitors Effective Date: Dec. 1, 2022 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
5.01.566 Pharmacotherapy of Thrombocytopenia
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 ...
5.01.582 Antibody-Drug Conjugates
https://www.premera.com/medicalpolicies/5.01.582.pdf#search=policy
MEDICAL POLICY - 5.01.582 Antibody-Drug Conjugates Effective Date: Jan. 1, 2023 Last ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
5.01.587 Hereditary Angioedema
https://www.premera.com/medicalpolicies/5.01.587.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.587 Hereditary Angioedema Effective Date: Nov. 1, 2022 ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
5.01.591 Immune Checkpoint Inhibitors
https://www.premera.com/medicalpolicies/5.01.591.pdf#search=policy
MEDICAL POLICY - 5.01.591 Immune Checkpoint Inhibitors Effective Date: Jan. 1, 2023 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
5.01.598 Phosphate Binders
https://www.premera.com/medicalpolicies/5.01.598.pdf#search=policy
PHARMACY POLICY - 5.01.598 Phosphate Binders Effective Date: Dec. 1, 2022 Last Revised: ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
6.01.38 Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty...
https://www.premera.com/medicalpolicies/6.01.38.pdf#search=policy
MEDICAL POLICY - 6.01.38 Percutaneous Balloon Kyphoplasty, Radiofrequency Kyphoplasty, and Mechanical Vertebral Augmentation BCBSA Ref. Policy: 6.01.38 Effective Date: Oct. 1, 2022 ...
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