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Medical Benefit Coverage Policies (BCP)Drug Determination Policies (DDP)Archived Medical Benefit Coverage Policies (BCP)Archived Drug Determination Policies (DDP)

Archived Medical Benefit Coverage Policies (BCP)

Attention - Physicians Health Plan (PHP) is now University of Michigan Health Plan (UM Health Plan). Documents published before this change may still have references to the PHP brand.
Archived

Archived PHP Medical Benefit Coverage Policies (BCP)

Infertility Services

(

BCP-72

)
Effective Date:
1/1/2024

Infertility Services

(

BCP-72

)
Effective Date:
1/1/2023

Infertility Services

(

BCP-72

)
Effective Date:
1/1/2022

Infertility Services

(

BCP-72

)
Effective Date:
1/1/2021

Infertility Services

(

BCP-72

)
Effective Date:
10/1/2019

Infertility Services

(

BCP-72

)
Effective Date:
1/1/2018

Inpatient Rehabilitation (IPR) Services

(

BCP-23

)
Effective Date:
10/1/2022

Inpatient Rehabilitation (IPR) Services

(

BCP-23

)
Effective Date:
10/1/2021

Inpatient Rehabilitation (IPR) Services

(

BCP-23

)
Effective Date:
8/7/2020

Inpatient Rehabilitation (IPR) Services

(

BCP-23

)
Effective Date:
1/1/2020

Kidney Transplantation

(

BCP-51

)
Effective Date:
4/1/2020

Kidney Transplantation

(

BCP-51

)
Effective Date:
4/1/2019

Kidney Transplantation

(

BCP-51

)
Effective Date:
4/1/2018

Liver Transplantation

(

BCP-75 v.6

)
Effective Date:
4/1/2023

Liver Transplantation

(

BCP-75 v.5

)
Effective Date:
7/1/2022

Liver Transplantation

(

BCP-75

)
Effective Date:
4/1/2022

Liver Transplantation

(

BCP-75

)
Effective Date:
7/1/2021

Liver Transplantation

(

BCP-75

)
Effective Date:
10/1/2020

Liver Transplantation

(

BCP-75

)
Effective Date:
10/1/2019

Liver Transplantation

(

BCP-75

)
Effective Date:
10/1/2018

Lung Transplantation

(

BCP-70

)
Effective Date:
7/1/2023

Lung Transplantation

(

BCP-70

)
Effective Date:
7/1/2022

Lung Transplantation

(

BCP-70

)
Effective Date:
7/1/2021

Lung Transplantation

(

BCP-70

)
Effective Date:
10/1/2020

Lung Transplantation

(

BCP-70

)
Effective Date:
10/1/2019

Lung Transplantation

(

BCP-70

)
Effective Date:
10/1/2018

Observation Care Services

(

BCP-04

)
Effective Date:
1/1/2023

Observation Care Services

(

BCP-04

)
Effective Date:
1/1/2022

Observation Care Services

(

BCP-04

)
Effective Date:
1/1/2021

Observation Care Services

(

BCP-04

)
Effective Date:
1/1/2020

Observation Care Services

(

BCP-04

)
Effective Date:
1/1/2019

Orthognathic Surgery

(

BCP-36

)
Effective Date:
4/1/2023

Orthognathic Surgery

(

BCP-36

)
Effective Date:
4/1/2022

Orthognathic Surgery

(

BCP-36

)
Effective Date:
4/1/2021

Orthognathic Surgery

(

BCP-36

)
Effective Date:
4/1/2020

Orthognathic Surgery

(

BCP-36

)
Effective Date:
1/1/2019

Orthognathic Surgery

(

BCP-36

)
Effective Date:
4/1/2018

Outpatient Cardiac Rehabilitation Therapy Services

(

BCP-08

)
Effective Date:
1/1/2023

Outpatient Cardiac Rehabilitation Therapy Services

(

BCP-08

)
Effective Date:
1/1/2022

Outpatient Cardiac Rehabilitation Therapy Services

(

BCP-08

)
Effective Date:
1/1/2021

Outpatient Cardiac Rehabilitation Therapy Services

(

BCP-08

)
Effective Date:
1/1/2020

Outpatient Cardiac Rehabilitation Therapy Services

(

BCP-08

)
Effective Date:
7/1/2018

Outpatient High Tech Radiology and Nuclear Medicine

(

BCP-39

)
Effective Date:
1/1/2023

Outpatient High Tech Radiology and Nuclear Medicine

(

BCP-39

)
Effective Date:
1/1/2022

Outpatient Pulmonary Rehabilitation Therapy Services

(

BCP-07

)
Effective Date:
4/1/2023

Outpatient Pulmonary Rehabilitation Therapy Services

(

BCP-07

)
Effective Date:
4/1/2022

Outpatient Pulmonary Rehabilitation Therapy Services

(

BCP-07

)
Effective Date:
4/1/2022

Outpatient Pulmonary Rehabilitation Therapy Services

(

BCP-07

)
Effective Date:
8/7/2020

Outpatient Pulmonary Rehabilitation Therapy Services

(

BCP-07

)
Effective Date:
1/1/2020

Outpatient Pulmonary Rehabilitation Therapy Services

(

BCP-07

)
Effective Date:
7/1/2018

Outpatient Rehabilitation-Habilitation Services-Speech Therapy

(

BCP-57

)
Effective Date:
7/1/2023

Outpatient Rehabilitation-Habilitation Services-Speech Therapy

(

BCP-57

)
Effective Date:
7/1/2023

Outpatient Rehabilitation-Habilitation Services-Speech Therapy

(

BCP-57 v.5

)
Effective Date:
7/1/2022

Outpatient Rehabilitation-Habilitation Services-Speech Therapy

(

BCP-57

)
Effective Date:
4/1/2021

Outpatient Rehabilitation-Habilitation Services-Speech Therapy

(

BCP-57

)
Effective Date:
8/7/2020

Outpatient Rehabilitation-Habilitation Services-Speech Therapy

(

BCP-57

)
Effective Date:
4/1/2020

Outpatient Rehabilitation-Habilitation Services-Speech Therapy

(

BCP-57

)
Effective Date:
10/1/2019

Outpatient Rehabilitation-Habilitation Services-Speech Therapy

(

BCP-57

)
Effective Date:
1/1/2019

Outpatient Rehabilitative-Habilitative Services-Physical and Occupational Therapy

(

BCP-06

)
Effective Date:
10/1/2022

Outpatient Rehabilitative-Habilitative Services-Physical and Occupational Therapy

(

BCP-06

)
Effective Date:
4/1/2022

Outpatient Rehabilitative-Habilitative Services-Physical and Occupational Therapy

(

BCP-06

)
Effective Date:
4/1/2022

Outpatient Rehabilitative-Habilitative Therapy Services-Physical and Occupational

(

BCP-06

)
Effective Date:
4/1/2021

Outpatient Rehabilitative-Habilitative Therapy Services-Physical and Occupational

(

BCP-06

)
Effective Date:
8/7/2020

Outpatient Rehabilitative-Habilitative Therapy Services-Physical and Occupational

(

BCP-06

)
Effective Date:
1/1/2020

Outpatient Rehabilitative-Habilitative Therapy Services-Physical and Occupational

(

BCP-06

)
Effective Date:
4/1/2019

Pancreas Kidney Transplant and Pancreas Transplant Alone

(

BCP-71

)
Effective Date:
10/1/2019

Pancreas Transplantation

(

BCP-71 v.6

)
Effective Date:
4/1/2023

Pancreas Transplantation

(

BCP-71 v.5

)
Effective Date:
7/1/2022

Pancreas Transplantation

(

BCP-71

)
Effective Date:
4/1/2022

Pancreas Transplantation

(

BCP-71

)
Effective Date:
7/1/2021

Pancreas-Kidney Transplantation and Pancreas Alone Transplantation - Simultaneous

(

BCP-71

)
Effective Date:
10/1/2018

Pre-Transplant Services

(

BCP-33

)
Effective Date:
1/1/2023

Pre-Transplant Services

(

BCP-33

)
Effective Date:
1/1/2022

Pre-Transplant Services

(

BCP-33

)
Effective Date:
1/1/2021

Preventative Health Services

(

BCP-45

)
Effective Date:
4/1/2018

Preventive Health Services

(

BCP-45

)
Effective Date:
1/1/2022

Preventive Health Services

(

BCP-45

)
Effective Date:
10/1/2021

Preventive Health Services

(

BCP-45

)
Effective Date:
7/1/2021

Preventive Health Services

(

BCP-45

)
Effective Date:
1/1/2021

Preventive Health Services

(

BCP-45

)
Effective Date:
7/1/2020

Preventive Health Services

(

BCP-45

)
Effective Date:
1/1/2019

Renal Transplantation

(

BCP-51 v.7

)
Effective Date:
4/1/2023

Renal Transplantation

(

BCP-51 v.6

)
Effective Date:
7/1/2022

Renal Transplantation

(

BCP-51

)
Effective Date:
4/1/2022

Renal Transplantation

(

BCP-51

)
Effective Date:
7/1/2021

Repair of Brow Ptosis

(

BCP-76

)
Effective Date:
7/1/2022

Repair of Brow Ptosis

(

BCP-76

)
Effective Date:
7/1/2021

Repair of Brow Ptosis

(

BCP-76

)
Effective Date:
10/1/2020

Repair of Brow Ptosis

(

BCP-76

)
Effective Date:
10/1/2019

Repair of Brow Ptosis

(

BCP-76

)
Effective Date:
1/1/2019

Retransplantation and Pediatric Transplantation

(

BCP-17 v.3

)
Effective Date:
4/1/2023

Retransplantation and Pediatric Transplantation

(

BCP-17 v.2

)
Effective Date:
7/1/2022

Retransplantation and Pediatric Transplantation

(

BCP-17

)
Effective Date:
4/1/2022

Retransplantation and Pediatric Transplantation

(

BCP-17

)
Effective Date:
4/1/2021

Sacral Nerve Stimulation for Urinary and Fecal Incontinence

(

BCP-81

)
Effective Date:
7/1/2023

Spinal Cord Stimulation for Pain Management

(

BCP-73

)
Effective Date:
7/1/2023

Spinal Cord Stimulation for Pain Management

(

BCP-73

)
Effective Date:
7/1/2022

Spinal Cord Stimulation for Pain Management

(

BCP-73

)
Effective Date:
7/1/2021

Spinal Cord Stimulation for Pain Management

(

BCP-73

)
Effective Date:
10/1/2020

Spinal Cord Stimulation for Pain Management

(

BCP-73

)
Effective Date:
10/1/2019
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