CommercialPrior AuthMedium impact
Medical Policy and Coding Updates - December 2024
Premera Blue Cross·WA · Oncology, Hematology, Endocrinology +4 more·Medical Policy
Effective date
Jan 3, 2025
We identified it
Jun 16, 2026
Summary
Premera Blue Cross implemented multiple policy updates with staggered effective dates from January 3 to March 5, 2025, affecting medical necessity criteria, drug coverage, and prior authorization requirements across various specialties including surgical lymphedema treatment, oncology drugs, and specialty medications. Most significantly, several medications now require trial and failure of preferred alternatives before coverage approval.
Action Required
By January 3, 2025: Update prior authorization protocols to require trial and failure of preferred products for Remodulin, Glassia, non-preferred trastuzumab products (Herceptin, Ogivri), and non-preferred rituximab products (Rituxan). By February 7, 2025: Update GnRH analog authorization processes to extend initial authorization from 6 to 12 months and add new documentation requirements for gender dysphoria treatment. By March 5, 2025: Implement new medical necessity criteria for lymphedema/lipedema surgical treatments requiring plastic surgeon involvement and BMI ≤35 kg/m². Billing team must update system edits and notify providers of new step therapy requirements to prevent claim denials.