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.
| Title | Last Updated | Category |
|---|---|---|
| Assisted Reproductive Technologies Open a PDF 4.01.05 | 2026-01-15 | Women's Health (Obstetrics & Gynecology) |
| Artificial Lumbar Intervertebral Disc Open a PDF 7.01.63 | 2026-02-25 | Bone & Joints (Orthopedic) |
| Artificial Cervical Intervertebral Disc Open a PDF 7.01.80 | 2025-07-11 | Bone & Joints (Orthopedic) |
| Aqueous Drainage Devices (Stents and Shunts) for Glaucoma Open a PDF 9.01.18 | 2026-01-27 | Eyes (Ophthalmology) |
| Applied Behavioral Analysis Open a PDF 3.01.11 | 2025-09-03 | Behavioral Health (Psychiatry/Psychology) |
| Angioplasty and Stenting of Extracranial, Intracranial and Vertebral Arteries Open a PDF 7.01.110 | 2025-12-23 | Nervous Systems (Neurology) |
| Ambulance: Land/Ground Open a PDF 10.01.07 | 2026-03-24 | Miscellaneous |
| Ambulance Air Open a PDF 11.01.06 | 2026-03-24 | Miscellaneous |
| Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HSCT) Open a PDF 7.02.02 | 2026-03-04 | Transplants |
| Allergy Testing Open a PDF 2.01.10 | 2025-07-24 | Ear, Nose & Throat (Otorhinolaryngology) |
