Clinical Policy Directory

• Adult Strabismus Surgery 1311 effect 3.1.2025.pdf
• Adult Strabismus Surgery 1311 effect 3.2025 SPANISH.pdf
• Amniotic Membrane 1312 effect 5.2025.pdf
• Amniotic Membrane 1312 eEffect 5.2025 SPANISH.pdf
• Botulinum Toxin 1325 8.2025.pdf
• Botulinum Toxin 1325 effect 8.2025 SPANISH.pdf
• Cataract Surgery 1300 effect 3.2025.pdf
• Cataract Surgery 1300 effective 3.2025 SPANISH.pdf
• Complement Inhibitors for Geographic Atrophy 1349 effect 12.1.2025.pdf
• Complement Inhibitors for Geographic Atrophy 1349 effect 12.1.2025 SPANISH.pdf
• Complement Inhibitors for Geographic Atrophy 1349 effect 11.1.2024-11.30.2025.pdf
• Complement Inhibitors for Geographic Atrophy 1349 effect 11.1.2024-11.30.2025 SPANISH.pdf
• Corneal Pachymetry 1307 effect 7.2025.pdf
• Corneal Pachymetry 1307 7.2025 Spanish.pdf
• Corneal Topography and Tomography 1314 effect 5.2025.pdf
• Corneal Topography and Tomography 1314 effect 5.2025 SPANISH.pdf
• Corticosteroid Implants and Injections 1346 effect 12.1.2025.pdf
• Corticosteroid Implants and Inections 1346 effect 12.2025 SPANISH.pdf
• Corticosteroid Implants and Injections 1346 effect 10.1.2024-11.30.2025.pdf
• Corticosteroid Implants and Injections 1346 effect 10.2024-11.30.2025 SPANISH.pdf
• Dextenza 1348 effect 6.1.2025.pdf
• Dextenza 1348 effect 6.2025 SPANISH.pdf
• Durysta 1343 effect 5.1.2025.pdf
• Durysta 1343 effect 5.2025 Spanish.pdf
• Electrophysiology Testing 1334 effect 10.1.2025.pdf
• Electrophysiology Testing 1334 effec 10.2025 SPANISH.pdf
• Electrophysiology Testing 1334 effect 10.1.2024-9.30.2025.pdf
• Electrophysiology Testing 1334 effect 10.12024-9.30.2025 SPANISH.pdf
• Experimental and Investigational Services 1323 6.1.2025.pdf
• Experimental and Investigational Services 1323 6.2025 SPANISH.pdf
• Extended Ophthalmoscopy 1335 effect 10.1.2025.pdf
• Extended Ophthalmoscopy 1335 effect 10.2025 Spanish.pdf
• Extended Ophthalmoscopy 1335 effect 9.1.2024-9.30.2025.pdf
• Extended Ophthalmoscopy 1335 effect 9.2024-9.30.2025 Spanish.pdf
• External Ocular Photography 1338 effect 10.1.2025.pdf
• External Ocular Photography 1338 effect 10.2025 SPANISH.pdf
• External Ocular Photography 1338 effect 9.1.2024-9.30.2025.pdf
• External Ocular Photography 1338 effect 9.2024-9.30.2025 SPANISH.pdf
• Eye Exams 1316 effect 6.2025.pdf
• Eye Exams 1316 effect 6.2025 SPANISH.pdf
• Eyelid Lesion Removal 1321 effect 10.1.2025.pdf
• Eyelid Lesion Removal 1321 effect 10.2025 SPANISH.pdf
• Eyelid Lesion Removal 1321 effect 11.2024-9.30.2025.pdf
• Eyelid Lesion Removal 1321 effect 11.2024-9.30.2025 SPANISH.pdf
• Eyelid and Brow Surgery 1301 effect 4.1.2025.pdf
• Eyelid and Brow Surgery 1301 effective 4.2025 SPANISH.pdf
• Fundus Photography 1331 effect 10.1.2025.pdf
• Fundus Photography 1331 effect 10.1.2025 SPANISH.pdf
• Fundus Photography 1331 effect 9.1.2024-9.30.2025.pdf
• Fundus Photography 1331 effect 9.2024-9.30.2025 SPANISH.pdf
• Glaucoma Surgery 1327 effect 4.1.2025.pdf
• Glaucoma Surgery 1327 effective 4.2025 SPANISH.pdf
• Iris Prosthesis 1340 effect 10.1.2025.pdf
• Iris Prosthesis 1340 effect 10.2025 SPANISH.pdf
• Iris Prosthesis 1340 effect 9.1.2024-9.30.2025.pdf
• Iris Prosthesis 1340 effect 9.2024-9.30.2025 SPANISH.pdf
• Keratoconus and Related Corneal Ectasias 1328 7.2025.pdf
• Keratoconus and Related Corneal Ectasias 1328 effect 7.2025 SPANISH.pdf
• Keratoplasty Corneal Transplant and Keratectomy 1315 effect 4.1.2025.pdf
• Keratoplasty Corneal Transplant and Keratectomy 1315 effect 4.2025 SPANISH.pdf
• Laser Peripheral Iridotomy 1322 effect 6.1.2025.pdf
• Laser Peripheral Iridotomy 1322 effect 6.2025 SPANISH.pdf
• Laser Photocoagulation and Cryotherapy 1326 effect 10.1.2025.pdf
• Laser Photocoagulation and Cryotherapy 1326 effect 10.2025 Spanish.pdf
• Laser Photocoagulation and Cryotherapy 1326 effect 10.1.2024-9.30.2025.pdf
• Laser Photocoagulation and Cryotherapy 1326 effect 10.2024-9.30.2025 Spanish.pdf
• Laser Trabeculoplasty 1308 effec 10.1.2025.pdf
• Laser Trabeculoplasty 1308 effec 10.2025 Spanish.pdf
• Laser Trabeculoplasty 1308 effect 9.1.2024-9.30.2025.pdf
• Laser Trabeculoplasty 1308 effect 9.1.2024-9.30.2025 Spanish.pdf
• Low Vision Eval and Rehab 1318 6.1.2025.pdf
• Low Vision Eval and Rehab 1318 effec 6.2025 SPANISH.pdf
• Medically Necessary Contact Lenses 1309 8.1.2025.pdf
• Medically Necessary Contact Lenses 1309 effect 8.2025 SPANISH.pdf
• Meibomian Gland Diagnostics and Therapies 1341 effect 12.1.2025.pdf
• Meibomian Gland Diagnostics and Therapies 1341 effect 12.2025 SPANISH.pdf
• Meibomian Gland Diagnostics and Therapies 1341 effect 9.1.2024-11.30.2025.pdf
• Meibomian Gland Diagnostics and Therapies 1341 effect 9.2024-11.30.2025 SPANISH.pdf
• Optical Coherence Tomography 1304 effect 8.1.2025.pdf
• Optical Coherence Tomography 1304 effect 8.1.2025 Spanish.pdf
• Perimetry Visual Field Testing 1319 effect 10.1.2025.pdf
• Perimetry Visual Field Testing 1319 effec 10.2025 SPANISH.pdf
• Perimetry Visual Field Testing 1319 effect 9.1.2024-9.30.2025.pdf
• Perimetry Visual Field Testing 1319 effec 9.2024-9.30.2025 SPANISH.pdf
• Posterior Capsulotomy 1305 effect 7.1.2025.pdf
• Posterior Capsulotomy 1305 effect 7.1.2025 SPANISH.pdf
• Pterygium Surgery 1329 effect 7.1.2025.pdf
• Pterygium Surgery 1329 effect 7.1.2025 SPANISH.pdf
• Refraction 1310 effect 3.1.2025.pdf
• Refraction 1310 effect 3.1.2025 SPANISH.pdf
• Refractive Surgery 1333 effect 7.1.2025.pdf
• Refractive Surgery 1333 effect 7.1.2025 SPANISH.pdf
• Retinal Angiography 1313 effect 5.1.2025.pdf
• Retinal Angiography 1313 effect 5.1.2025 Spanish.pdf
• Specialty Spectacle Lenses 1330 effect 8.1.2025.pdf
• Specialty Spectacle Lenses 1330 effect 8.2025 Spanish.pdf
• Telemedicine 1336 effect 12.1.2025.pdf
• Telemedicine 1336 effect 12.2025 SPANISH.pdf
• Telemedicine 1336 effect 5.1.2025-11.30.2025.pdf
• Telemedicine 1336 effect 5.2025-11.30.2025 SPANISH.pdf
• Vascular Endothelial Growth Factor Inhibitors 1317 effect 12.1.2025.pdf
• Vascular Endothelial Growth Factor Inhibitors 1317 effec 12.2025 SPANISH.pdf
• Vascular Endothelial Growth Factor Inhibitors 1317 effec 5.1.2025-11.30.2025.pdf
• Vascular Endothelial Growth Factor Inhibitors 1317 effec 5.2025-11.30.2025 SPANISH.pdf
• Verteporfin (Visudyne) 1345 7.1.2025.pdf
• Verteporfin Visudyne 1345 effect 7.2025 SPANISH.pdf
• Vision Therapy and Orthoptics 1337 effect 10.1.2025.pdf
• Vision Therapy and Orthoptics 1337 effect 10.2025 SPANISH.pdf
• Vision Therapy and Orthoptics 1337 effect 10.1.2024-9.30.2025.pdf
• Vision Therapy and Orthoptics 1337 effect 10.2024-9.30.2025 SPANISH.pdf
• iDose TR 1350 effect 5.1.2025.pdf
• iDose TR 1350 effect 5.2025 SPANISH.pdf