• 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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5.01.512 Botulinum Toxin
https://www.premera.com/medicalpolicies/5.01.512.pdf#search=policy
MEDICAL POLICY - 5.01.512 Botulinum Toxins Effective Date: May 1, 2024 Last Revised: ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | APPENDIX | ...
5.01.533 mTOR Kinase Inhibitors
https://www.premera.com/medicalpolicies/5.01.533.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.533 mTOR Kinase Inhibitors Effective Date: July 1, 2023 ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
5.01.544 Prostate Cancer Targeted Therapies
https://www.premera.com/medicalpolicies/5.01.544.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.544 Prostate Cancer Targeted Therapies Effective Date: ... POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY ∞ ...
5.01.553 Myalept® (metreleptin)
https://www.premera.com/medicalpolicies/5.01.553.pdf#search=policy
PHARMACY POLICY - 5.01.553 Myalept ® (metreleptin) Effective Date: June 1, 2023 Last ... below to be directed to that section. POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | ...
5.01.552 Hetlioz® (tasimelteon)
https://www.premera.com/medicalpolicies/5.01.552.pdf#search=policy
PHARMACY POLICY - 5.01.552 Hetlioz® (tasimelteon) Effective Date: June 1, 2023 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
5.01.561 Repository Corticotropin Injection
https://www.premera.com/medicalpolicies/5.01.561.pdf#search=policy
MEDICAL POLICY - 5.01.561 Repository Corticotropin Injection BCBSA Ref. Policy: 5.01.17 Effective Date: May 1, 2024 Last Revised: April 22, 2024 Replaces: 5.01.17 RELATED MEDICAL ...
7.01.126 Image-Guided Minimally Invasive Decompression for Spinal...
https://www.premera.com/medicalpolicies/7.01.126.pdf#search=policy
MEDICAL POLICY - 7.01.126 Image-Guided Minimally Invasive Decompression for Spinal Stenosis BCBSA Ref. Policy: 7.01.126 Effective Date: July 1, 2024 Last Revised: June 10, 2024 ...
7.01.142 Surgery for Groin Pain in Athletes
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, 2024 Last Revised: April 8, 2024 Replaces: N/A RELATED MEDICAL ...
7.01.573 Hip Arthroplasty in Adults
https://www.premera.com/medicalpolicies/7.01.573.pdf#search=policy
MEDICAL POLICY - 7.01.573 Hip Arthroplasty in Adults Effective Date: Jan. 1, 2024 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
7.01.588 Percutaneous Electrical Nerve Stimulation and Percutaneous...
https://www.premera.com/medicalpolicies/7.01.588.pdf#search=policy
MEDICAL POLICY - 7.01.588 Percutaneous Electrical Nerve Stimulationand Percutaneous Neuromodulation Therapy BCBSA Ref. Policy: 7.01.29 Effective Date: Oct. 1, 2023 Last Revised: ...
7.03.07 Lung and Lobar Lung Transplant
https://www.premera.com/medicalpolicies/7.03.07.pdf#search=policy
MEDICAL POLICY - 7.03.07 Lung and Lobar Lung Transplant BCBSA Ref. Policy: 7.03.07 Effective Date: Nov. 1, 2023 Last Revised: Oct. 9, 2023 Replaces: Extracted from 7.03.509 ...
8.01.531 Hematopoietic Cell Transplantation for Waldenström...
https://www.premera.com/medicalpolicies/8.01.531.pdf#search=policy
MEDICAL POLICY - 8.01.531 Hematopoietic Cell Transplantation for Waldenström Macroglobulinemia BCBSA Ref. Policy: 8.01.54 Effective Date: Jan. 1, 2024 Last Revised: April 11, ...
8.01.55 Stem Cell Therapy for Peripheral Arterial Disease
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: April 1, 2024 Last Revised: Mar. 25, 2024 Replaces: N/A ...
10.01.520 Review for Coverage in the Absence of a Medical Policy...
https://www.premera.com/medicalpolicies/10.01.520.pdf#search=policy
BENEFIT COVERAGE GUIDELINE - 10.01.520 Review for Coverage in the Absence of a Medical Policy, Pharmacy Policy, or Utilization Management Guideline Effective Date: Apr. 1, 2023 ...
10.01.533 Non-covered Experimental/Investigational Services
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 | ...
2.02.09 Closure Devices for Patent Foramen Ovale and Atrial Septal...
https://www.premera.com/medicalpolicies/2.02.09.pdf#search=policy
MEDICAL POLICY - 2.02.09 Closure Devices for Patent Foramen Ovale and Atrial Septal Defects BCBSA Ref. Policy: 2.02.09 Effective Date: Aug. 1, 2023 Last Revised: July 10, 2023 ...
2.04.509 Cardiovascular Risk Panels
https://www.premera.com/medicalpolicies/2.04.509.pdf#search=policy
MEDICAL POLICY - 2.04.509 Cardiovascular Risk Panels BCBSA Ref. Policy: 2.04.65 Effective Date: May 1, 2024 Last Revised: April 9, 2024 Replaces: 2.04.509 RELATED MEDICAL ...
2.04.62 Multimarker Serum Testing Related to Ovarian Cancer
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. 2024 Last Revised: Feb. 12, 2024 Replaces: N/A ...
3.01.510 Applied Behavior Analysis (ABA)
https://www.premera.com/medicalpolicies/3.01.510.pdf#search=policy
MEDICAL POLICY - 3.01.510 Applied Behavior Analysis (ABA) Effective Date: Jan. 1, 2024 ... below to be directed to that section. POLICY CRITERIA | CODING | RELATED INFORMATION ...
5.01.559 IL-5 Inhibitors
https://www.premera.com/medicalpolicies/5.01.559.pdf#search=policy
PHARMACY / MEDICAL POLICY - 5.01.559 IL-5 Inhibitors Effective Date: July 1, 2024 Last ... POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE ...
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