Archived Policies
| Policy Number | Policy Title | Effective Date Start | Retire Date |
| CP.MP.31 | Cosmetic and Reconstructive Procedures (PDF) | October 1, 2024 | January 1, 2026 |
| CP.MP.37 | Bariatric surgery (PDF) | June 1, 2025 | January 1, 2026 |
| CC.PP.036 | New Patient (PDF) | February 7, 2017 | February 1, 2026 |
| CP.MP.126 | Sacroiliac Joint Fusion (PDF) | March 1, 2019 | June 15, 2026 |
| CP.MP.95 | Gender Affirming Procedures (PDF) | March 1, 2019 | June 15, 2026 |
| CP.MP.51 | Reduction Mammoplasty and Gynecomastia Surgery (PDF) | October 1, 2025 | July 15, 2026 |
| Policy Number | Policy Title | Effective Date Start | Retire Date |
| Policy Number | Policy Title | Effective Date Start | Retire Date |