CommercialCoverageHigh impact
Medical Policy and Coding Updates - December 2025
Premera Blue Cross·WA · Orthopedics, Gastroenterology, General Surgery +6 more·Medical Policy
Effective date
Jan 2, 2026
We identified it
Jun 16, 2026
Summary
Premera Blue Cross updated medical necessity criteria and coverage policies for multiple conditions including new policies for shoulder procedures, hernia repairs, and various drug formulary changes. Key changes include updated preferred drug lists for biologics, new coverage for shoulder arthroscopy/arthrotomy, and revised criteria for immune checkpoint inhibitors with staggered effective dates from January 2 through March 4, 2026.
Action Required
By January 2, 2026: Update prior authorization systems for new shoulder arthroscopy/arthrotomy policies (7.01.602, 7.01.605) and abdominal hernia repairs (7.01.600). Update formulary preferences for biologics including Yuflyma, Avsola (now preferred) and Cyltezo, Zymfentra (now non-preferred). By February 6, 2026: Implement new gastroesophageal reflux surgery criteria and updated cranial orthoses policies. By March 4, 2026: Update electrophysiology studies and endovascular stent graft policies. Billing team must verify current preferred drug status before submitting claims to avoid denials.