• 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/7.01.573.pdf#search=policy
MEDICAL POLICY - 7.01.573 Hip Arthroplasty in Adults Effective Date: Nov. 1, 2024 Last ... 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/7.03.08.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/8.01.55.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, 2025 Last Revised: Mar. 10, 2025 Replaces: N/A ...
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/2.01.71.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/2.01.98.pdf#search=policy
MEDICAL POLICY - 2.01.98 Orthopedic Applications of Platelet-Rich Plasma BCBSA Ref. Policy: 2.01.98 Effective Date: July 1, 2024 Last Revised: Jan. 1, 2025 Replaces: N/A RELATED ...
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/3.01.510.pdf#search=policy
MEDICAL POLICY - 3.01.510 Applied Behavior Analysis (ABA) Effective Date: Sept. 1, 2024 ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
https://www.premera.com/medicalpolicies/5.01.584.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.584 CGRP Inhibitors for Migraine Prophylaxis BCBSA Ref. Policy: 5.01.29 Effective Date: Mar. 1, 2025 Last Revised: Feb. 11, 2025 Replaces: N/A ...
https://www.premera.com/medicalpolicies/5.01.590.pdf#search=policy
PHARMACY POLICY - 5.01.590 Bruton's Kinase Inhibitors Effective Date: Mar. 1, 2025 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.595.pdf#search=policy
PHARMACY/MEDICAL POLICY - 5.01.595 Injectable Clostridial Collagenase for Fibroproliferative Disorders BCBSA Ref. Policy: 5.01.19 Effective Date: Apr. 1, 2025 Last Revised: Mar. ...
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: ...
https://www.premera.com/medicalpolicies/5.01.617.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.617 Folate Antimetabolites Effective Date: Mar. 1, 2025 ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.624.pdf#search=policy
MEDICAL POLICY - 5.01.624 Alpha-1 Proteinase Inhibitors Effective Date: Feb. 1, 2025 Last ... Medical Necessity criteria within this policy DOES NOT apply to Alaska fully- insured ...
https://www.premera.com/medicalpolicies/5.01.629.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.629 Pharmacologic Treatment of Psoriasis Effective Date: May 1, 2025* Last Revised: Apr. 8, 2025 Replaces: N/A *This policy has been updated. Click ...
https://www.premera.com/medicalpolicies/5.01.638.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.638 Omisirge (omidubicel) BCBSA Ref. Policy: 8.01.68 Effective Date: May 1, 2025 Last Revised: Apr. 21, 2025 Replaces: N/A RELATED MEDICAL ...