• 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
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8.01.26 Hematopoietic Cell Transplantation for Acute Myeloid...
https://www.premera.com/medicalpolicies/8.01.26.pdf#search=policy
MEDICAL POLICY - 8.01.26 Hematopoietic Cell Transplantation for Acute Myeloid Leukemia BCBSA Ref. Policy: 8.01.26 Effective Date: April 1, 2024 Last Revised: Mar. 25, 2024 ...
8.01.30 Hematopoietic Cell Transplantation for Chronic Myeloid...
https://www.premera.com/medicalpolicies/8.01.30.pdf#search=policy
MEDICAL POLICY - 8.01.30 Hematopoietic Cell Transplantation for Chronic Myeloid Leukemia BCBSA Ref. Policy: 8.01.30 Effective Date: April 1, 2024 Last Revised: Mar. 25, 2024 ...
8.01.520 Hematopoietic Cell Transplantation for Acute Lymphoblastic...
https://www.premera.com/medicalpolicies/8.01.520.pdf#search=policy
MEDICAL POLICY - 8.01.520 Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia BCBSA Ref. Policy: 8.01.32 Effective Date: April 1, 2024 Last Revised: Mar. 25, 2024 ...
8.03.01 Functional Neuromuscular Electrical Stimulation
https://www.premera.com/medicalpolicies/8.03.01.pdf#search=policy
MEDICAL POLICY - 8.03.01 Functional Neuromuscular Electrical Stimulation BCBSA Ref. Policy: 8.03.01 Effective Date: June 1, 2024 Last Revised: May 13, 2024 Replaces: N/A RELATED ...
2.01.57 Electrostimulation and Electromagnetic Therapy for Treating...
https://www.premera.com/medicalpolicies/2.01.57.pdf#search=policy
MEDICAL POLICY - 2.01.57 Electrostimulation and Electromagnetic Therapy for Treating Wounds BCBSA Ref. Policy: 2.01.57 Effective Date: Mar. 1, 2024 Last Revised: Feb. 26, 2024 ...
2.01.73 Actigraphy
https://www.premera.com/medicalpolicies/2.01.73.pdf#search=policy
MEDICAL POLICY - 2.01.73 Actigraphy BCBSA Ref. Policy: 2.01.73 Effective Date: Sept. 1, 2023 Last Revised: Aug. 7, 2023 Replaces: N/A RELATED MEDICAL POLICIES: None Select a ...
5.01.639 Immune Prophylaxis for Respiratory Syncytial Virus
https://www.premera.com/medicalpolicies/5.01.639.pdf#search=policy
MEDICAL POLICY - 5.01.639 Immune Prophylaxis for Respiratory Syncytial Virus BCBSA Ref. Policy: 5.01.10 Effective Date: Nov. 1, 2023 Last Revised: Oct. 10, 2023 Replaces: 5.01.10 ...
7.03.11 Total Artificial Hearts and Implantable Ventricular Assist...
https://www.premera.com/medicalpolicies/7.03.11.pdf#search=policy
MEDICAL POLICY - 7.03.11 Total Artificial Hearts and Implantable Ventricular Assist Devices BCBSA Ref. Policy: 7.03.11 Effective Date: Nov. 1, 2023 Last Revised: Oct. 9, 2023 ...
8.01.24 Hematopoietic Cell Transplantation for Miscellaneous...
https://www.premera.com/medicalpolicies/8.01.24.pdf#search=policy
MEDICAL POLICY - 8.01.24 Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults BCBSA Ref. Policy: 8.01.24 Effective Date: April 1, 2024 Last Revised: Mar. ...
8.01.511 Hematopoietic Cell Transplantation for Solid Tumors...
https://www.premera.com/medicalpolicies/8.01.511.pdf#search=policy
MEDICAL POLICY - 8.01.511 Hematopoietic Cell Transplantation for Solid Tumors of Childhood BCBSA Ref. Policy: 8.01.34 Effective Date: April 1, 2024 Last Revised: Mar. 25, 2024 ...
8.03.501 Chiropractic and Other Manipulation Services
https://www.premera.com/medicalpolicies/8.03.501.pdf#search=policy
MEDICAL POLICY - 8.03.501 Chiropractic and Other Manipulation Services Effective Date: ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
9.02.500 Orthodontic Services for Treatment of Congenital Craniofacial...
https://www.premera.com/medicalpolicies/9.02.500.pdf#search=policy
MEDICAL POLICY - 9.02.500 Orthodontic Services for Treatment of Congenital Craniofacial ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
10.01.511 Medical Policy and Clinical Guidelines: Definitions...
https://www.premera.com/medicalpolicies/10.01.511.pdf#search=policy
ADMINISTRATIVE GUIDELINE - 10.01.511 Medical Policy and Clinical Guidelines: Definitions ... section is for your general knowledge and is not to be taken as policy coverage criteria. ...
2.01.17 Sublingual Immunotherapy as a Technique of Allergen-Specific...
https://www.premera.com/medicalpolicies/2.01.17.pdf#search=policy
MEDICAL POLICY - 2.01.17 Sublingual Immunotherapy as a Technique of Allergen- Specific Therapy BCBSA Ref Policy: 2.01.17 Effective Date: Jan. 1, 2024 Last Revised: Dec. 11, 2023 ...
5.01.514 Herceptin (trastuzumab) and Other HER2 Inhibitors
https://www.premera.com/medicalpolicies/5.01.514.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.514 Herceptin (trastuzumab) and Other HER2 Inhibitors ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
5.01.520 Antidepressants: Pharmacy Medical Necessity Criteria...
https://www.premera.com/medicalpolicies/5.01.520.pdf#search=policy
PHARMACY POLICY - 5.01.520 Antidepressants: Pharmacy Medical Necessity Criteria for ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
5.01.603 Epidermal Growth Factor Receptor (EGFR) Inhibitors
https://www.premera.com/medicalpolicies/5.01.603.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.603 Epidermal Growth Factor Receptor (EGFR) Inhibitors ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
7.01.84 Semi-Implantable and Fully Implantable Middle Ear Hearing...
https://www.premera.com/medicalpolicies/7.01.84.pdf#search=policy
MEDICAL POLICY - 7.01.84 Semi-Implantable and Fully Implantable Middle Ear Hearing Aids BCBSA Ref. Policy: 7.01.84 Effective Date: May 1, 2024 Last Revised: April 8, 2024 ...
8.01.521 Radioembolization for Primary and Metastatic Tumors...
https://www.premera.com/medicalpolicies/8.01.521.pdf#search=policy
MEDICAL POLICY - 8.01.521 Radioembolization for Primary and Metastatic Tumors of the Liver BCBSA Ref. Policy: 8.01.43 Effective Date: Oct. 1, 2023 Last Revised: Sept. 11, 2023 ...
7.01.120 Facet Arthroplasty
https://www.premera.com/medicalpolicies/7.01.120.pdf#search=policy
MEDICAL POLICY - 7.01.120 Facet Arthroplasty BCBSA Ref. Policy: 7.01.120 Effective Date: July 1, 2024 Last Revised: June 10, 2024 Replaces: N/A RELATED MEDICAL POLICIES: 7.01.107 ...
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