EviCore by Evernorth · PayerPolicy · EVICORE-MEDICAL_DRUG-1FB7B0BCFD65
Summary of the payer’s published policy. Not a coverage determination — confirm with EviCore by Evernorth before submitting.
Free account. Policy pages stay open to everyone.
Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.
Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.
| Code | Code system | Status in this policy |
|---|---|---|
| J0177 | HCPCS | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Q5147 | HCPCS | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |