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.

or
Showing 161– 180 of 304 Results
Title Last Updated Category
Ketamine for the Treatment of Psychiatric Disorders Open a PDF 3.01.13 2025-01-30 Behavioral Health (Psychiatry/Psychology)
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms (Effective 2025-09-16) Open a PDF 2.02.53 2025-06-16 Lab Tests (pathology)
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms Open a PDF 2.02.53 2024-03-29 Lab Tests (pathology)
Intraocular Lens (IOL) Implants Open a PDF 9.01.14 2024-10-25 Eyes (Ophthalmology)
Intradiscal Procedures (Effective 2025-10-15) Open a PDF 7.01.112 2025-07-11 Bone & Joints (Orthopedic)
Intradiscal Procedures Open a PDF 7.01.112 2025-04-08 Bone & Joints (Orthopedic)
Interfacility Transfer of a Registered Inpatient Open a PDF 11.01.18 2025-04-01 Miscellaneous
Inflammatory Markers of Coronary Artery Disease Risk Open a PDF 2.02.15 2024-07-29 Lab Tests (pathology)
Implantable Cardioverter Defibrillator (ICD) Open a PDF 7.01.06 2025-02-14 Heart & Blood Vessels (Cardiovascular)
Implantable Bone Conduction Hearing Aids Open a PDF 7.01.77 2025-04-23 Ear, Nose & Throat (Otorhinolaryngology)
Immunizations Open a PDF 2.01.42 2025-01-30 Vaccines (Immunizations)
Hyperbaric Oxygen Therapy (HBOT) Open a PDF 2.01.07 2025-07-01 Miscellaneous
Home Birth by Certified Nurse Midwives Open a PDF 11.01.23 2024-10-25 Women's Health (Obstetrics & Gynecology)
Home Automatic External Defibrillators (AEDs) and Wearable Cardioverter Defibrillators (WCDs) Open a PDF 1.01.42 2025-07-01 Heart & Blood Vessels (Cardiovascular)
Hip Arthroplasty (Effective 2025-10-15) Open a PDF 7.01.96 2025-07-11 Bone & Joints (Orthopedic)
Hip Arthroplasty Open a PDF 7.01.96 2025-01-08 Bone & Joints (Orthopedic)
Showing 161– 180 of 304 Results

 

GDPR Notification Content