Clinical Policy Directory
Adult Strabismus Surgery 1311 4.2026.pdf
Adult Strabismus Surgery 1311 effective 4.2026 SPANISH.pdf
Amniotic Membrane 1312 4.2026.pdf
Amniotic Membrane 1312 effective 4.2026 SPANISH.pdf
Botulinum Toxin 1325 6.2026.pdf
Botulinum Toxin 1325 effect 6.2026 SPANISH.pdf
Botulinum Toxin 1325 8.1.2025-5.31.2026.pdf
Botulinum Toxin 1325 effect 8.1.2025-5.31.2026 SPANISH.pdf
Cataract Surgery 1300 effect 4.2026.pdf
Cataract Surgery 1300 effective 4.2026 SPANISH.pdf
Complement Inhibitors for Geographic Atrophy 1349 12.2025.pdf
Complement Inhibitors for Geographic Atrophy 1349 effective 12.2025 SPANISH.pdf
Corneal Pachymetry 1307 6.2026.pdf
Corneal Pachymetry 1307 effect 6.2026 Spanish.pdf
Corneal Pachymetry 1307 effect 7.2025-5.31.2026.pdf
Corneal Pachymetry 1307 effective 7.2025-5.31.2026 SPANISH.pdf
Corneal Topography and Tomography 1314 5.2026.pdf
Corneal Topography and Tomography 1314 effective 5.2026 SPANISH.pdf
Corticosteroid Implants and Injections 1346 12.2025.pdf
Corticosteroid Implants and Injections 1346 effective 12.2025 SPANISH.pdf
Dextenza 1348 6.2026.pdf
Dextenza 1348 effect 6.2025 SPANISH.pdf
Dextenza 1348 6.1.2025-5.31.2026.pdf
Dextenza 1348 effective 6.1.2025-5.31.2026 SPANISH.pdf
Durysta bimatoprost implant 1343 effect 4.2026.pdf
Durysta bimatoprost implant 1343 effective 4.2026 Spanish.pdf
Electrophysiology Testing 1334 10.2025.pdf
Electrophysiology Testing 1334 effective 10.2025 SPANISH.pdf
Experimental & Investigational Services 1323 6.2026.pdf
Experimental and Investigational Services 1323 effect 6.2026 SPANISH.pdf
Experimental and Investigational Services 1323 6.1.2025-5.31.2026.pdf
Experimental and Investigational Services 1323 effective 6.2025-5.31.2026 SPANISH.pdf
Extended Ophthalmoscopy 1335 10.2025.pdf
Extended Ophthalmoscopy 1335 effective 10.2025 Spanish.pdf
External Ocular Photography 1338 10.2025.pdf
External Ocular Photography 1338 effective 10.2025 SPANISH.pdf
Eye Exams 1316 6.2026.pdf
Eye Exams 1316 effect 6.2026 SPANISH.pdf
Eye Exams 1316 6.1.2025-5.31.2026.pdf
Eye Exams 1316 effective 6.2025 SPANISH.pdf
Eyelid Lesion Removal 1321 10.2025.pdf
Eyelid Lesion Removal 1321 effective 10.2025 SPANISH.pdf
Eyelid and Brow Surgery 1301 effect 4.2026.pdf
Eyelid and Brow Surgery 1301 effective 4.2026 SPANISH.pdf
Fundus Photography 1331 10.2025.pdf
Fundus Photography 1331 effective 10.2025 SPANISH.pdf
Glaucoma Surgery 1327 4.2026.pdf
Glaucoma Surgery 1327 effective 4.2026 SPANISH.pdf
IDose TR 1350 6.2026.pdf
IDose TR 1350 effect 6.2026 SPANISH.pdf
IDose TR 1350 5.1.2025-5.31.2026.pdf
IDose TR 1350 effect 5.2025-5.31.2026 SPANISH.pdf
Iris Prosthesis 1340 10.2025.pdf
Iris Prosthesis 1340 effective 10.2025 SPANISH.pdf
Keratoconus and Related Corneal Ectasias 1328 7.2026.pdf
Keratoconus and Related Corneal Ectasias 1328 effect 7.2026 SPANISH.pdf
Keratoconus and Related Corneal Ectasias 1328 7.1.2025-6.30.2026.pdf
Keratoconus and Related Corneal Ectasias 1328 effect 7.2025-6.30.2026 SPANISH.pdf
Keratoplasty and Keratectomy 1315 5.2026.pdf
Keratoplasty and Keratectomy 1315 effect 5.2026 SPANISH.pdf
Laser Peripheral Iridotomy 1322 6.2026.pdf
Laser Peripheral Iridotomy 1322 effect 6.2026 SPANISH.pdf
Laser Peripheral Iridotomy 1322 6.1.2025-5.31.2026.pdf
Laser Peripheral Iridotomy 1322 effect 6.1.2025-5.31.2026 SPANISH.pdf
Laser Photocoagulation and Cryotherapy 1326 effective 10.2025 Spanish.pdf
Laser Photocoagulation and Cryotherapy 1326 10.2025.pdf
Laser Trabeculoplasty 1308 effect 10.2025.pdf
Laser Trabeculoplasty 1308 effective 10.2025 SPANISH.pdf
Low Vision Eval and Rehab 1318 6.2026.pdf
Low Vision Eval and Rehab 1318 effec 6.2026 SPANISH.pdf
Low Vision Eval and Rehab 1318 6.1.2025-5.31.2026.pdf
Low Vision Eval and Rehab 1318 effective 6.2025-5.31.2026 SPANISH.pdf
Medically Necessary Contact Lenses 1309 7.2026.pdf
Medically Necessary Contact Lenses 1309 7.2026 SPANISH.pdf
Medically Necessary Contact Lenses 1309 8.1.2025-6.30.2026.pdf
Medically Necessary Contact Lenses 1309 effective 8.2025-61.2026 SPANISH.pdf
Meibomian Gland Diagnostics and Therapies 1341 12.2025.pdf
Meibomian Gland Diagnostics and Therapies 1341 effective 12.2025 SPANISH.pdf
Optical Coherence Tomography 1304 6.2026.pdf
Optical Coherence Tomography 1304 effect 6.2026 Spanish.pdf
Optical Coherence Tomography 1304 8.1.2025-5.31.2026.pdf
Optical Coherence Tomography 1304 effective 8.20255.31.2026 SPANISH.pdf
Perimetry Visual Field Testing 1319 10.2025.pdf
Perimetry Visual Field Testing 1319 effect 10.2025 SPANISH.pdf
Posterior Capsulotomy 1305 7.2026.pdf
Posterior Capsulotomy 1305 effec 7.2026 SPANISH.pdf
Posterior Capsulotomy 1305 7.1.2025-6.30.2026.pdf
Posterior Capsulotomy 1305 effective 7.2025-6.30.2026 SPANISH.pdf
Pterygium Surgery 1329 7.2026.pdf
Pterygium Surgery 1329 effect 7.2026 SPANISH.pdf
Pterygium Surgery 1329 7.1.2025-6.30.2026.pdf
Pterygium Surgery 1329 effective 7.2025-6.30.2026 SPANISH.pdf
Refraction 1310 4.2026.pdf
Refraction 1310 effective 4.2026 SPANISH.pdf
Refractive Surgery 1333 6.2026.pdf
Refractive Surgery 1333 effective 6.2026 SPANISH.pdf
Refractive Surgery 1333 7.1.2025-5.31.2026.pdf
Refractive Surgery 1333 effective 7.1.2025-5.31.2026 SPANISH.pdf
Retinal Angiography 1313 4.2026.pdf
Retinal Angiography 1313 effective 4.2026 Spanish.pdf
Specialty Spectacle Lenses 1330 6.2026.pdf
Specialty Spectacle Lenses 1330 effect 6.2026 Spanish.pdf
Specialty Spectacle Lenses 1330 8.1.2025-5.31.2026.pdf
Specialty Spectacle Lenses 1330 effective 8.2025 SPANISH.pdf
Telemedicine 1336 4.2026.pdf
Telemedicine 1336 effective 4.2026 SPANISH.pdf
Vascular Endothelial Growth Factor Inhibitors 1317 5.2026.pdf
Vascular Endothelial Growth Factor Inhibitors 1317 effective 5.2026 SPANISH.pdf
Verteporfin Visudyne 1345 6.2026.pdf
Verteporfin Visudyne 1345 6.2026 SPANISH.pdf
Verteporfin Visudyne 1345 7.1.2025-5.31.2026.pdf
Verteporfin Visudyne 1345 effect 7.2025-5.31.2026 SPANISH.pdf
Vision Therapy and Orthoptics 1337 10.2025.pdf
Vision Therapy and Orthoptics 1337 effective 10.2025 SPANISH.pdf