View Medical Policies

For certain member contracts, the Health Plan has delegated utilization management of the following services to eviCore Healthcare MSI, LLC d/b/a eviCore Healthcare: implantable cardiac devices, radiology/imaging, radiation therapy, and musculoskeletal services (large joint replacement, pain management, and spine services). The Health Plan has adopted eviCore’s medical policies and guidelines as a basis for the determination of medical necessity and appropriateness of care.

Please refer member-specific questions to the Customer Care number on the back of the member card. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service.

To view drug policies, guidelines and supporting documentation, please visit our View Drug Policies page.

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Showing 81– 100 of 311 Results
Title Last Updated Category
Deep Brain Stimulation Open a PDF 7.01.23 2025-04-23 Nervous Systems (Neurology)
Dental and Oral Care under Medical Plans Open a PDF 7.01.21 2025-05-30 Dental
Dental Crowns and Veneers Open a PDF 13.01.02 2025-05-30 Dental
Dental Implants Open a PDF 13.01.01 2025-05-30 Dental
Dental Inlays and Onlays Open a PDF 13.01.03 2025-05-30 Dental
Disability Determination For Extension of Benefits After Coverage Termination Open a PDF 10.01.11 2024-09-04 Miscellaneous
Durable Medical Equipment Standard and Non-Standard Open a PDF 1.01.00 2024-09-04 Durable Medical Equipment & Supplies
Dynamic Adjustable Braces Open a PDF 1.01.35 2025-02-27 Bone & Joints (Orthopedic)
Electrical Stimulation as a Treatment for Pain and Other Medical Conditions Open a PDF 1.01.55 2025-02-04 Durable Medical Equipment & Supplies
Electromagnetic Navigation Bronchoscopy Open a PDF 6.01.40 2025-02-14 Lungs (Respiratory)
Emergency Care Services Open a PDF 10.01.12 2025-04-01 Miscellaneous
Endometrial Ablation Open a PDF 4.01.01 2025-02-27 Women's Health (Obstetrics & Gynecology)
Enteral Nutrition Open a PDF 10.01.03 2025-02-27 Food (Nutrition)
Epidural Steroid Injections (Effective 2025-10-15) Open a PDF 7.01.115 2025-07-11 Bone & Joints (Orthopedic)
Epidural Steroid Injections Open a PDF 7.01.115 2025-04-01 Bone & Joints (Orthopedic)
Erectile Dysfunction Open a PDF 7.01.30 2025-04-08 Urinary System (Genitourinary)
Evoked Potentials Open a PDF 2.01.27 2025-05-30 Nervous Systems (Neurology)
Showing 81– 100 of 311 Results

 

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