Premera Bluecross Coverage Criteria
Latest Premera Bluecross coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-049.02.501 Orthognathic SurgeryPremera Bluecross medical policy defining medical necessity criteria, documentation, coding, and coverage positions for orthognathic surgery (corrective jaw surgery) including indications related to congenital anomalies, trauma/tumor, masticatory malocclusion, TMJ-related malocclusion, and OSA; also states investigational and cosmetic exclusions and limited coverage for surgical splints and virtual surgery planning.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-04Negative Pressure Wound Therapy (NPWT) DevicesThis policy governs coverage and clinical criteria for powered and single-use negative pressure wound therapy devices for outpatient wound care, affecting providers treating adolescents and adults (and notes investigational status in children ≤11).All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-04Shoulder Open ProceduresDefines medical necessity criteria, documentation requirements, and coding guidance for open shoulder arthrotomy procedures in adults for specific indications such as AC separation, subacromial decompression/acromioplasty, full-thickness rotator cuff repair, distal clavicle resection, shoulder dislocation, and synovectomy.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-04Shoulder Open ProceduresDefines medical necessity criteria, documentation requirements, and coding guidance for open shoulder arthrotomy procedures (e.g., AC separation repair, acromioplasty, rotator cuff repair, distal clavicle resection, dislocation repair, synovectomy) for Premera Bluecross members/providers.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-04Testosterone laboratory testing and measurement (coverage criteria)Defines when serum total, free, bioavailable testosterone and related hormone tests (e.g., SHBG, albumin, estradiol, DHT) are reimbursable, not reimbursable, and provides analytical/testing guidance; applies to Premera Bluecross coverage determinations.All Premera Bluecross updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-09-01Site of Service Ambulatory Service Center (ASC) SelectDefines medical necessity criteria and prior authorization requirements for the appropriate site of service (ASC, outpatient hospital on/off-campus, inpatient) for certain elective ambulatory surgical and diagnostic procedures for adult patients.All Premera Bluecross updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-09-01Site of Service Ambulatory Service Center (ASC) SelectDefines medical necessity criteria and prior authorization expectations for the site of service (ASC, hospital outpatient, inpatient) for certain elective adult surgical procedures and lists included procedure categories and CPT codes; intended for providers and affects Premera-covered members and their providers.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Upper Gastrointestinal (UGI) Endoscopy in AdultsMedical necessity and site-of-service coverage criteria for upper gastrointestinal endoscopy (EGD/UGI) in adults (age 19+), including indications, documentation, and coding guidance for Premera Bluecross.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Upper Gastrointestinal (UGI) Endoscopy in AdultsMedical necessity criteria, site-of-service guidance, documentation, and coding for upper GI endoscopy (EGD) for individuals aged 19 and older; intended for providers and payers reviewing coverage decisions.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-07Denosumab ProductsDefines medical necessity, coverage criteria, coding, and benefit application for denosumab products (brand, biosimilars) for osteoporosis, prevention of skeletal-related events, hypercalcemia of malignancy, giant cell tumor of bone, and related indications for Premera Bluecross members and providers.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-07Denosumab ProductsDefines medical necessity, coverage criteria, coding, documentation, and benefit handling for denosumab products (multiple brands and biosimilars) for Premera Bluecross members.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-07Denosumab ProductsDefines medical necessity, administration benefit assignment, and coverage criteria for denosumab products for osteoporosis, prevention of skeletal-related events, hypercalcemia of malignancy, and giant cell tumor of bone for Premera Blue Cross members and providers.All Premera Bluecross updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-08-07Denosumab ProductsDefines medical necessity, coverage criteria, dosing limits, and benefit application for branded and biosimilar denosumab products for members of Premera Bluecross.All Premera Bluecross updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-08-07Denosumab productsThis policy defines medical necessity, coverage criteria, coding, documentation, and benefit application for denosumab products for Premera Bluecross members.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-07Mobile Cardiac Outpatient Telemetry and Implantable Loop RecordersDefines medical necessity, site-of-service considerations, documentation, and coding for implantable loop recorders (ILRs) and mobile cardiac outpatient telemetry (MCOT) for outpatient cardiac rhythm monitoring.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-07Mobile Cardiac Outpatient Telemetry and Implantable Loop RecordersDefines medical necessity, site-of-service considerations, documentation, and coding for use of MCOT and ILR devices for outpatient cardiac rhythm monitoring for Premera Blue Cross members.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-07Mobile Cardiac Outpatient Telemetry and Implantable Loop RecordersDefines medical necessity criteria for ILR implantation and use of MCOT for outpatient cardiac rhythm monitoring, site-of-service guidance for ILR implantation, documentation requirements, coding references, and evidence summary. This part covers indications, required prior monitoring, exclusions, and related coding/evidence.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial HypertensionDefines medical necessity criteria for specific medications used to treat pulmonary arterial hypertension (PAH, WHO Group 1) and when combination therapy is allowed; intended for providers and payer coverage determinations.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Advanced Therapies for Pharmacological Treatment of Pulmonary Arterial HypertensionDefines when specific advanced medications (oral, inhaled, IV/SC) for pulmonary arterial hypertension (PAH, WHO Group 1) may be considered medically necessary for Premera members and informs providers about coverage criteria and documentation expectations.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Antibody-Drug ConjugatesDefines medical necessity criteria, coding, documentation, and authorization lengths for specific antibody-drug conjugate (ADC) therapies under the medical benefit for Premera Bluecross members.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Antibody-Drug ConjugatesDefines medical necessity, coverage criteria, authorization lengths, documentation, and coding for specific antibody-drug conjugate therapies managed under the medical benefit for Premera Blue Cross members.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Antiemetic MedicationsPharmacy benefit policy describing medical necessity criteria, limits, and documentation for coverage of specific antiemetic drugs (oncology-, pregnancy-, motion sickness-, and post-operative–related) for Premera Bluecross members.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Antiemetic MedicationsPharmacy benefit policy governing medical necessity criteria, quantity limits, and approval conditions for specific antiemetic drugs (including cancer-, pregnancy-, motion sickness-, and postoperative-related uses) for Premera Blue Cross members and prescribers.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Antiemetic MedicationsPharmacy benefit policy that defines medical necessity criteria, limits, and documentation for specific antiemetic drugs used for cancer-related, motion-sickness, pregnancy-related, and other indicated nausea/vomiting conditions. Applies to providers managing pharmacy benefit requests for Premera BlueCross members.All Premera Bluecross updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Antipsychotics (Second‑generation antipsychotic pharmacy coverage)Defines pharmacy benefit medical necessity criteria, age limits, quantity and duration limits, and documentation requirements for oral second‑generation (atypical) antipsychotics and select other antipsychotic products for Premera Bluecross members.All Premera Bluecross updates
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Tool Description
Search Premera Bluecross coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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