CommercialPrior AuthHigh impact
Medical Policy and Coding Updates - April 2026
Premera Blue Cross·WA · Cardiology, Gastroenterology, General Surgery +7 more·Medical Policy
Effective date
Apr 1, 2026
We identified it
Jun 16, 2026
Summary
Premera Blue Cross has updated multiple medical and pharmacy policies with new prior authorization requirements, site of service reviews, and coverage criteria changes. Key changes include new drugs requiring site of service administration review, updated criteria for various treatments including bariatric surgery and shoulder arthroscopy, and new coverage for implantable loop recorders.
Action Required
By April 1, 2026: Billing team must update prior authorization processes for multiple new drugs including Exdensur, Givlaari, Keytruda Qlex, Yimmugo, Leqvio, Amvuttra, Onpattro, and Rystiggo which now require site of service administration review. Update bariatric surgery billing to include single anastomosis duodeno-ileal bypass with sleeve gastrectomy as covered procedure. Remove prior conservative management requirements for initial hernia repairs. Update shoulder arthroscopy documentation requirements to specify both medication therapy and physical measures trials. Verify all effective dates as they vary from April 1 through July 2, 2026.