CommercialCoverageHigh impact
Medical Policy and Coding Updates - January 2026
Premera Blue Cross·WA · Cardiology, Gastroenterology, Orthopedics +3 more·Medical Policy
Effective date
Jan 2, 2026
We identified it
Jun 16, 2026
Summary
Premera Blue Cross updated multiple medical policies for 2026 with staggered effective dates from January 2 through April 8, 2026. Key changes include new coverage policies for cardiac procedures, shoulder surgeries, hernia repairs, and significant updates to preferred/non-preferred drug formularies affecting biologics and specialty medications.
Action Required
By January 2, 2026: Review and update prior authorization workflows for new policies including abdominal hernia repairs, shoulder arthroscopy/arthrotomy, cardiac telemetry, and EP studies. Update formulary preferences in billing system for adalimumab, infliximab, and rituximab products - several biosimilars are now preferred over brand names. By February 6, 2026: Add site-of-service review requirements for UGI endoscopy procedures. By March 4, 2026: Implement prior auth for electrophysiology studies and endovascular stent grafts. By April 8, 2026: Update cardiac telemetry policies to include implantable loop recorders. Billing team must verify current formulary status before submitting claims for specialty biologics to avoid denials.