• 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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406 results found for policy
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: Jul. 1, 2025 Last Revised: Jun. 9, ...
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 ...
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/7.01.590.pdf#search=policy
MEDICAL POLICY - 7.01.590 Shoulder Arthroplasty BCBSA Ref. Policy: N/A Effective Date: Jun. 1, 2025 Last Revised: May 12, 2025 Replaces: N/A RELATED MEDICAL POLICIES: None Select ...
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, 2025 Last Revised: Apr. 7, 2025 Replaces: N/A RELATED MEDICAL POLICIES: ...
https://www.premera.com/medicalpolicies/7.01.95.pdf#search=policy
MEDICAL POLICY - 7.01.95 Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors BCBSA Ref. Policy: 7.01.95 Effective Date: Dec. 1, 2024 Last Revised: Jan. 1, ...
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 Effective Date: Nov. 1, 2024 Last Revised: Oct. 7, 2024 Replaces: Extracted from 7.03.509 ...
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/7.03.08.pdf#search=policy
MEDICAL POLICY - 7.03.08 Heart/Lung Transplant BCBSA Ref. Policy: 7.03.08 Effective Date: Nov. 1, 2024 Last Revised: Oct. 7, 2024 Replaces: Extracted from 7.03.509 RELATED MEDICAL ...
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: Jul. 1, 2025 Replaces: N/A RELATED MEDICAL ...
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: Oct. 1, 2024 Last Revised: Sept. 9, 2024 Replaces: N/A RELATED MEDICAL ...
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: Jul. 1, 2025 Last Revised: Jun. 9, 2025 Replaces: N/A RELATED ...
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: Mar. 1, 2025 Last Revised: Feb. 10, 2025 Replaces: 2.01.519 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/2.04.62.pdf#search=policy
MEDICAL POLICY - 2.04.62 Multimarker Serum Testing Related to Ovarian Cancer BCBSA Ref. Policy: 2.04.62 Effective Date: Mar. 1, 2025 Last Revised: Feb. 10, 2025 Replaces: N/A ...
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/5.01.582.pdf#search=policy
MEDICAL POLICY - 5.01.582 Antibody-Drug Conjugates Effective Date: Jul. 1, 2025 Last ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
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/5.01.613.pdf#search=policy
PHARMACY POLICY - 5.01.613 Oral Iron Chelating Agents BCBSA Ref. Policy: 8.01.02 Effective Date: Mar. 1, 2025 Last Revised: Feb. 24, 2025 Replaces: N/A RELATED MEDICAL POLICIES: ...