CommercialCoverageHigh impact
Medical Policy and Coding Updates - March 2025
Premera Blue Cross·WA, AK · Rheumatology, Gastroenterology, Dermatology +7 more·Medical Policy
Effective date
Apr 20, 2025
We identified it
Jun 16, 2026
Summary
Premera Blue Cross updated multiple medical policies affecting pharmacy coverage, diagnostic testing, and surgical procedures with staggered effective dates from April to July 2025. Key changes include new prior authorization requirements, preferred drug tier changes, and coverage determinations for various treatments including asthma medications, genetic testing, and imaging guidelines.
Action Required
By April 20, 2025: Billing teams must update prior authorization workflows for Carelon Medical Benefits Management radiology and genetic testing guidelines. Review and update preferred drug lists - move Humira (adalimumab) from preferred to non-preferred status. By May 6, 2025: Update carpal tunnel release surgery billing to ensure conservative therapy documentation requirements are met. By June 6, 2025: Flag multitarget PCR testing for bacterial vaginosis as investigational/non-covered. By July 1, 2025: Update pharmacy policies for psoriasis, arthropathies, and IBD treatments. Failure to comply may result in claim denials.