• 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
https://www.premera.com/medicalpolicies/7.01.137.pdf#search=policy
MEDICAL POLICY - 7.01.137 Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease BCBSA Ref. Policy: 7.01.137 Effective Date: Feb. 1, 2023 Last ...
https://www.premera.com/medicalpolicies/7.01.142.pdf#search=policy
MEDICAL POLICY - 7.01.142 Surgery for Groin Pain in Athletes BCBSA Ref. Policy: 7.01.142 Effective Date: May 1, 2022 Last Revised: April 11, 2022 Replaces: N/A RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/7.01.144.pdf#search=policy
MEDICAL POLICY - 7.01.144 Patient-Specific Cutting Guides for Joint Arthroplasty BCBSA Ref. Policy: 7.01.144 Effective Date: July 1, 2022 Last Revised: June 13, 2022 Replaces: N/A ...
https://www.premera.com/medicalpolicies/7.01.159.pdf#search=policy
MEDICAL POLICY - 7.01.159 Sphenopalatine Ganglion Block for Headache BCBSA Ref. Policy: 7.01.159 Effective Date: Feb. 1, 2023 Last Revised: Jan. 9, 2023 Replaces: N/A RELATED ...
https://www.premera.com/medicalpolicies/7.01.29.pdf#search=policy
MEDICAL POLICY - 7.01.29 Percutaneous Electrical Nerve Stimulation and Percutaneous Neuromodulation Therapy BCBSA Ref. Policy: 7.01.29 Effective Date: Aug. 1, 2022 Last Revised: ...
https://www.premera.com/medicalpolicies/7.01.551.pdf#search=policy
MEDICAL POLICY - 7.01.551 Lumbar Spine Decompression Surgery: Discectomy, Foraminotomy, ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/7.01.567.pdf#search=policy
MEDICAL POLICY - 7.01.567 Surgical Treatments for Lymphedema and Lipedema BCBSA Ref. Policy: 7.01.162, 7.01.169, 7.01.173 Effective Date: Feb. 1, 2023 Last Revised: Jan. 9, 2023 ...
https://www.premera.com/medicalpolicies/7.01.573.pdf#search=policy
MEDICAL POLICY - 7.01.573 Hip Arthroplasty in Adults Effective Date: Aug. 1, 2022 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/8.01.55.pdf#search=policy
MEDICAL POLICY - 8.01.55 Stem Cell Therapy for Peripheral Arterial Disease BCBSA Ref. Policy: 8.01.55 Effective Date: Apr. 1, 2022 Last Revised: Mar. 21, 2022 Replaces: N/A ...
https://www.premera.com/medicalpolicies/8.01.62.pdf#search=policy
MEDICAL POLICY - 8.01.62 Electronic Brachytherapy for Nonmelanoma Skin Cancer BCBSA Ref. Policy: 8.01.62 Effective Date: Sept. 1, 2022 Last Revised: Aug. 22, 2022 Replaces: N/A ...
https://www.premera.com/medicalpolicies/2.02.16.pdf#search=policy
MEDICAL POLICY - 2.02.16 Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis BCBSA Ref. Policy: 2.02.16 Effective Date: ...
https://www.premera.com/medicalpolicies/2.02.18.pdf#search=policy
MEDICAL POLICY - 2.02.18 Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia BCBSA Ref. Policy: 2.02.18 Effective Date: Aug. 1 2022 Last Revised: July ...
https://www.premera.com/medicalpolicies/2.04.100.pdf#search=policy
MEDICAL POLICY - 2.04.100 Cardiovascular Risk Panels BCBSA Ref. Policy: 2.04.100 Effective Date: Feb. 1, 2023 Last Revised: Jan. 23, 2023 Replaces: 2.04.509 RELATED MEDICAL ...
https://www.premera.com/medicalpolicies/5.01.519.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.519 Increlex® (mecasermin); Recombinant Human ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
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/5.01.562.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.562 Imlygic® (talimogene laherparepvec) Effective Date: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.564.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.564 Pharmacotherapy of Miscellaneous Autoimmune Diseases ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
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/5.01.589.pdf#search=policy
PHARMACY POLICY - 5.01.589 BRAF and MEK Inhibitors Effective Date: Jan. 1, 2023 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.590.pdf#search=policy
PHARMACY POLICY - 5.01.590 Bruton's Kinase Inhibitors Effective Date: Mar. 1, 2023 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...