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Medical Policy Guidelines

Prior authorization does not guarantee payment. Coverage of services is based on member eligibility and member’s benefits per the medical certificate of coverage at the time services are rendered.

Bariatric Surgery

Botox Injections

Dental Services Coverage Under Medical Plans

Dental Services in the Emergency Room

Genetic and Genomic Outpatient Testing

Oral/Orthognathic Surgery

Penile Prosthesis (Implant)

Phototherapy (SAD Lights) for Psychiatric Disorders

Prophylactic Mastectomy and Oophorectomy

Recurrent Pregnancy Loss

Reduction Mammaplasty

Rosacea Treatment

Varicose Vein Procedure