• 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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368 results found for policy
https://www.premera.com/medicalpolicies/5.01.559.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.559 IL-5 Inhibitors Effective Date: Oct. 1, 2023 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
https://www.premera.com/medicalpolicies/5.01.562.pdf#search=policy
MEDICAL POLICY - 5.01.562 Imlygic (talimogene laherparepvec) Effective Date: Dec. 1, 2023 ... 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/5.01.566.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/5.01.587.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.587 Hereditary Angioedema Effective Date: May 1, 2023 ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/5.01.591.pdf#search=policy
MEDICAL POLICY - 5.01.591 Immune Checkpoint Inhibitors Effective Date: Jan. 1, 2024 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: June 1, 2023 Last Revised: May 5, ...
https://www.premera.com/medicalpolicies/5.01.598.pdf#search=policy
PHARMACY POLICY - 5.01.598 Phosphate Binders Effective Date: Dec. 1, 2023 Last Revised: ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
https://www.premera.com/medicalpolicies/7.01.07.pdf#search=policy
MEDICAL POLICY - 7.01.07 Electrical Bone Growth Stimulation of the Appendicular Skeleton BCBSA Ref. Policy: 7.01.07 Effective Date: July 1, 2023 Last Revised: June 12, 2023 ...
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, 2024 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, 2023 Last Revised: Apr. 10, 2023 Replaces: N/A RELATED MEDICAL ...
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, 2024 Last Revised: Jan. 8, 2024 Replaces: N/A RELATED ...
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: Oct. 1, 2023 Last Revised: Sept. 11, 2023 Replaces: N/A ...
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: Jan. 1, 2024 Last Revised: Dec. 11, 2023 ...
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/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, 2023 Last Revised: July ...
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/2.04.100.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/5.01.545.pdf#search=policy
PHARMACY POLICY - 5.01.545 Tadalafil Products for Benign Prostatic Hyperplasia Effective ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...