Back to Chapter 4 Table of Contents Covered
Not Covered
Benefits
CC & IFP
Details and Limitations
EG
Chiropractic Care
Employer Group Members – Covered Services are available within VHP’s network of contracted providers and may be authorized through the member’s PCP or other VHP contracted provider. Coverage is limited to a maximum of 20 prior authorized visits per calendar year. In the event services require more than 20 prescribed visits per calendar year, justification is required from the requesting provider. Services, which are not chiropractic related such as x-rays or nutritional counseling, are not covered benefits and will not be reimbursed by VHP.
Cosmetic Surgery
Except for medically necessary cosmetic surgery or plastic surgery as specified under the EOC section “Mastectomies and Lymph Node Dissections,” cosmetic surgery and plastic surgery are excluded from coverage by VHP.
Contraceptive Methods
Coverage includes diaphragms, cervical caps, contraceptive rings, contraceptive patches, and oral contraceptives (including emergency contraceptive pills). All FDA-approved contraceptive drugs, devices, and products available over the counter (OTC) are covered when prescribed by VHP contracted providers and filled at a VHP contracted pharmacy.
Dental Anesthesia
Diabetes Education, Management, & Treatment
Diabetes education and management are covered. For diabetes medication treatment, refer to VHP’s preferred medication formulary on VHP’s website. https://www.valleyhealthplan.org/sites/m/pn/Pharm/ Pages/Pharmacy.aspx
Dialysis
Durable Medical Equipment (DME)
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2021 / Provider Manual
CH 4: Member Benefits, Exclusions, & Limitations
