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Premera Blue CrossCommercial · Prior Auth · Medical Policy · WA, AK · Orthopedics, Neurosurgery, Neurology +16 moreMedium impact

Medical Policy and Coding Updates - August 2024

Effective date
Not stated in the notice
Identified
Jun 16, 2026

Summary

Effective August 2, 2024, the Premera HMO C3 and C5 Complement Inhibitors policy (5.01.571) is a new policy in which the confirmed granulocyte clone size is updated to 15% or greater for Soliris (eculizumab), Ultomiris (ravulizumab-cwvz), and Empaveli (pegcetacoplan) for paroxysmal nocturnal hemoglobinuria (PNH). Effective October 20, 2024, Carelon Medical Benefits Management clinical appropriateness guidelines for radiology, cardiology, genetic testing, radiation oncology and sleep were updated, including added indications for MRI and amyloid beta PET imaging in Alzheimer disease for patients considering or receiving lecanemab. Effective October 8, 2024, surgical treatment of femoral acetabular impingement is considered medically necessary when criteria are met.

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What to do

Action · 7 steps
01Already effective August 2, 2024: For the Premera HMO C3 and C5 complement inhibitors listed with the updated granulocyte clone size, the billing team should confirm the request meets the criteria in the current policy.
02Already effective July 1, 2024: For the Premera HMO drugs with new or updated medical necessity criteria, including the updated age requirements for Repatha, Praluent and Evkeeza, the billing team should confirm the request meets the current criteria.
03Libervant (diazepam) is limited to 10 films per 30 days.
04Xolair may not be used in combination with Tezspire for moderate to severe persistent asthma, and may not be used in combination with Dupixent or Nucala for chronic rhinosinusitis with nasal polyps.
05Filsuvez may not be used concurrently with Vyjuvek.
06Myasthenia gravis medication may not be used concurrently with Vyvgart, Vyvgart Hytrulo, Soliris, Ultomiris or Zilbrysq.
07Check current applicability of these policies before billing the affected services.

Codes mentioned

J9030Q4311Q4312Q4313Q4314Q4315Q4316Q4317Q4318Q4319Q4320Q4321Q4322Q4323Q4324Q4325Q4326Q4327Q4328Q4329Q4330Q4331Q4332Q4333H0008H0009H0010H0011J8611J8612J3393J3263C1605J735596161J7336J3394J3247J2267J7171J9361J232981382801458023080280

Original notice

Medical Policy and Coding Updates - August 2024
premera.com · Always check the source before changing claims.
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Related changes

See all Premera Blue Cross changes →
Medical Policy and Coding Updates - July 2024MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - January 2020MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - April 2024MediumNo effective date · Medical PolicyMedical Policy and Coding Updates - June 2024HighEffective Aug 2, 2024 · Medical PolicyBrowse every Premera Blue Cross change in the policy list

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