CommercialCoverageHigh impact
Medical Policy and Coding Updates - November 2025
Premera Blue Cross·WA · Oncology, Rheumatology, Gastroenterology +3 more·Medical Policy
Effective date
Jan 1, 2026
We identified it
Jun 16, 2026
Summary
Premera Blue Cross has issued extensive medical policy updates effective in multiple phases from January 1, 2026 through February 6, 2026. The changes include new coverage policies for surgical procedures, significant updates to drug formulary preferences requiring step therapy with preferred products, and new medical necessity criteria across multiple specialties including oncology, gastroenterology, orthopedics, and autoimmune conditions.
Action Required
Before January 1, 2026: Billing teams must update prior authorization workflows and formulary preferences for multiple drug categories including adalimumab products (now prefer Yuflyma over Cyltezo), infliximab products (now prefer Avsola), rituximab products (now prefer Riabni), and trastuzumab products (now prefer Ogivri). Update systems to require step therapy documentation showing trial and failure of preferred products before approving non-preferred alternatives. Review new coverage policies for shoulder arthroscopy, abdominal hernia repair, and gastroesophageal reflux surgery to ensure proper medical necessity documentation. Claims for non-preferred drugs without documented trial of preferred alternatives will be denied.