All policies are posted prior to their effective date. Below is a listing of the policy notifications that we have posted to our website as of July 25, 2012. Policy effective date Policy No. Notification title Notification issue date August 1, 2012 00.10.01s Services Paid Above Capitation for Health Maintenance Organization (HMO) Primary Care Physicians July 2, 2012 August 3, 2012 11.02.20d Maze Procedure July 3, 2012 August 8, 2012 11.02.01i Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence May 10, 2012 August 15, 2012 07.07.03i Photodynamic Therapy (PDT) Using Levulan^? Kerastick^? (Aminolevulinic Acid HCI [ALA]) or Metvixia^? (Methyl Aminolevulinate [MAL]) July 16, 2012 August 21, 2012 08.00.68d Ibandronate Sodium (Boniva^?) for Intravenous Injection May 23, 2012 September 1, 2012 00.03.02m Diagnostic Radiology Services Included in Capitation June 1, 2012 September 18, 2012 11.03.01c Repair of Cleft Lip and/or Cleft Palate June 23, 2012 October 1, 2012 12.01.01o Experimental/Investigational Services June 29, 2012 October 3, 2012 07.13.05f Photodynamic Therapy (PDT) Using Verteporfin (Visudyne^?) July 3, 2012 To view the policy notifications, visit our Medical Policy website, select Accept and Go to Medical Policy Online, and click on the Policy Notifications box. You can also view policy notifications using the NaviNet^? web portal by selecting Reference Tools from the Plan Transactions menu, then Medical Policy . Once these policies are in effect, they will be available by using the Search box on the Medical Policy homepage. Be sure to check back often, as the site is updated frequently.

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