CommercialPrior AuthMedium impact
Medical Policy and Coding Updates - June 2025
Premera Blue Cross·WA · Pulmonology, Pain Management, Ophthalmology +4 more·Medical Policy
Effective date
Jun 1, 2025
We identified it
Jun 16, 2026
Summary
Premera Blue Cross has updated multiple medical and pharmacy policies effective June-September 2025, including new coverage criteria for severe asthma treatments, genetic testing guidelines, atopic dermatitis medications, and various drug therapy protocols. Key changes include new medical necessity criteria for several specialty medications and updated prior authorization requirements.
Action Required
By September 5, 2025: Billing team must update prior authorization workflows for newly added medications including Quzyttir (cetirizine) injections, Prialt (ziconotide) for chronic pain, Visudyne (verteporfin) injections, and Veklury (remdesivir) infusions. Update system to reflect new medical necessity criteria for Zepbound (tirzepatide) for sleep apnea treatment and Nemluvio (nemolizumab-ilto) for atopic dermatitis. Review genetic testing authorization processes with Carelon MBM effective August 1, 2025, using sample collection date as date of service. Claims may be denied without proper prior authorization and medical necessity documentation.