All PlansCoverageHigh impact
Medical Policy and Coding Updates - April 2025
Premera Blue Cross·WA·Medical Policy
Effective date
Apr 20, 2025
We identified it
Jun 16, 2026
Summary
Multiple policy updates effective at various dates from April to August 2025, including new drugs for severe asthma, updated genetic testing guidelines, new medical necessity criteria for various treatments, and changes to pharmaceutical coverage tiers. Key changes include updated criteria for genetic testing, new policies for carpal tunnel surgery and atrial fibrillation treatment, and medication tier changes.
Action Required
By April 20, 2025: Billing team must review and implement multiple policy changes including updated genetic testing authorization requirements through Carelon provider portal, new medical necessity criteria for carpal tunnel surgery (policy 7.01.595), atrial fibrillation catheter ablation (policy 2.02.516), and updated pharmaceutical coverage tiers. Update prior authorization workflows for Humira (adalimumab) which moved from preferred to non-preferred status. Train staff on new date of service definitions for genetic testing (sample collection date) effective August 1, 2025. Access Carelon provider portal for real-time authorization processing.