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Archived Policies

Clinical Policies
Policy NumberPolicy TitleEffective Date StartRetire Date
CP.MP.31Cosmetic and Reconstructive Procedures (PDF)October 1, 2024January 1, 2026
CP.MP.37Bariatric surgery (PDF)June 1, 2025January 1, 2026
Pharmacy Policies
Policy NumberPolicy TitleEffective Date StartRetire Date
    
    
    
    
Payment Policies
Policy NumberPolicy TitleEffective Date StartRetire Date