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 201– 220 of 290 Results
Title Last Updated Category
Epidural Steroid Injections Open a PDF 7.01.115 2025-04-01 Bone & Joints (Orthopedic)
Enteral Nutrition Open a PDF 10.01.03 2025-02-27 Food (Nutrition)
Endometrial Ablation Open a PDF 4.01.01 2025-02-27 Women's Health (Obstetrics & Gynecology)
Emergency Care Services Open a PDF 10.01.12 2025-04-01 Miscellaneous
Electromagnetic Navigation Bronchoscopy Open a PDF 6.01.40 2025-02-14 Lungs (Respiratory)
Electrical Stimulation as a Treatment for Pain and Other Medical Conditions Open a PDF 1.01.55 2025-02-04 Durable Medical Equipment & Supplies
Dynamic Adjustable Braces Open a PDF 1.01.35 2025-02-27 Bone & Joints (Orthopedic)
Durable Medical Equipment Standard and Non-Standard Open a PDF 1.01.00 2024-09-04 Durable Medical Equipment & Supplies
Disability Determination For Extension of Benefits After Coverage Termination Open a PDF 10.01.11 2024-09-04 Miscellaneous
Dental Inlays and Onlays Open a PDF 13.01.03 2025-05-30 Dental
Dental Implants Open a PDF 13.01.01 2025-05-30 Dental
Dental Crowns and Veneers Open a PDF 13.01.02 2025-05-30 Dental
Dental and Oral Care under Medical Plans Open a PDF 7.01.21 2025-05-30 Dental
Deep Brain Stimulation Open a PDF 7.01.23 2025-04-23 Nervous Systems (Neurology)
Cryotherapy (Cold Therapy) Devices Open a PDF 1.01.21 2025-07-01 Bone & Joints (Orthopedic)
Cranial Orthotics Open a PDF 1.01.32 2025-05-30 Children's Health (Pediatrics)
Showing 201– 220 of 290 Results

 

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