EviCore by Evernorth prior authorization codes | Backwork

EviCore by Evernorth prior authorization codes

1,169 code entries across 838 active EviCore by Evernorth policies that Backwork has recorded as requiring prior authorization. Each policy links to its page and to the payer’s source.

Summary of the payer’s published policy. Not a coverage determination — confirm with EviCore by Evernorth before submitting.

Policies with prior authorization codes

1–50 of 838, by title

Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.

EviCore by Evernorth policies and the codes each marks as requiring prior authorization
Policy	Effective	Codes requiring prior authorization
Abatacept (Orencia)Effective 09/01/2022 - 07/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-78205D370875	Sep 1, 2022	J0129Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.
Abatacept (Orencia)Effective 10/01/2021 - 08/31/2022PayerPolicy · EVICORE-MEDICAL_DRUG-0A115FE2F3D6	Oct 1, 2021	J0129Inferred from policy title

Abatacept (Orencia)Effective 11/01/2020 - 09/30/2021PayerPolicy · EVICORE-MEDICAL_DRUG-BB29D3E80A90	Nov 1, 2020	J0129Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Abatacept (Orencia)Effective 11/02/2018 - 11/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-DE6F68AC3518	Nov 2, 2018	J0129Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Abatacept (Orencia)Effective 12/01/2019 - 10/31/2020PayerPolicy · EVICORE-MEDICAL_DRUG-809429E3989B	Dec 1, 2019	J0129Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

AbobotulinumtoxinA (Dysport)Effective 03/01/2019 - 08/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-9C67D0490987	Mar 1, 2019	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

AbobotulinumtoxinA (Dysport)Effective 06/01/2017 - 02/28/2019PayerPolicy · EVICORE-MEDICAL_DRUG-95C108088D0A	Jun 1, 2017	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

AbobotulinumtoxinA (Dysport)Effective 08/01/2022 - 07/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-E5CDB58BC804	Aug 1, 2022	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

AbobotulinumtoxinA (Dysport)Effective 09/01/2019 - 09/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-ACD57A2F68CD	Sep 1, 2019	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

AbobotulinumtoxinA (Dysport)Effective 09/01/2021 - 07/31/2022PayerPolicy · EVICORE-MEDICAL_DRUG-EC20C3C86E84	Sep 1, 2021	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

AbobotulinumtoxinA (Dysport)Effective 10/01/2020 - 08/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-88A9FF3F8188	Oct 1, 2020	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Actemra (tocilizumab)Effective 10/01/2023 - 09/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-30361C503142	Oct 1, 2023	J3262Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Acthar Gel (repository corticotropin injection)PayerPolicy · EVICORE-MEDICAL_DRUG-CFA3B45BB5B0	Jan 1, 2026	J0801Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Acthar Gel (repository corticotropin injection)Effective 02/01/2024 - 01/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-02D1F8FB0C51	Feb 1, 2024	J0801Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Acthar Gel (repository corticotropin injection)Effective 02/01/2025 - 12/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-A6B75E32413A	Feb 1, 2025	J0801Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Adakveo (crizanlizumab-tmca)PayerPolicy · EVICORE-MEDICAL_DRUG-76936323150D	Jan 1, 2026	J0791Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Adakveo (crizanlizumab-tmca)Effective 01/01/2025 - 12/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-0B7FC605914B	Jan 1, 2025	J0791Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Adakveo (crizanlizumab-tmca)Effective 02/01/2024 - 12/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-550393028D4A	Feb 1, 2024	J0791Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Advate, Adynovate, Afstyla, Altuviiio, Eloctate, Esperoct, Jivi, Kogenate FS, Kovaltry, Obizur, Novoeight, Nuwiq, Recombinate, Xyntha (antihemophilic factor [recombinant]) Hemofil M, Koate-DVI (antihemophilic factor [plasma deEffective 08/01/2024 - 07/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-21BB4FF39C03	Aug 1, 2024	J7182Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7185Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7188Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7190Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7192Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7204Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7205Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7207Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7210Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7211Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7214Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Adzynma (ADAMTS13 recombinant-krhn)PayerPolicy · EVICORE-MEDICAL_DRUG-10DB9DE908E9	Not recorded	J7171Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Adzynma (ADAMTS13 recombinant-krhn)Effective 04/01/2024 - 03/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-293C38076705	Apr 1, 2024	J7171Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Adzynma (ADAMTS13 recombinant-krhn)Effective 04/01/2025 - 03/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-A4B20C1FC495	Apr 1, 2025	J7171Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aflibercept (Eylea, Eylea HD, Pavblu) InjectionPayerPolicy · EVICORE-MEDICAL_DRUG-D37E50177633	Not recorded	J0177Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5147Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aflibercept (Eylea, Eylea HD, Pavblu) InjectionEffective 05/01/2025 - 04/30/2026PayerPolicy · EVICORE-MEDICAL_DRUG-C628BFC0F4DA	May 1, 2025	J0177Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5147Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aflibercept (Eylea, Eylea HD, Pavblu) InjectionEffective 05/01/2026 - 07/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-1FB7B0BCFD65	Not recorded	J0177Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5147Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Agalsidase Beta (Fabrazyme)Effective 01/01/2019 - 09/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-E66409271B4A	Jan 1, 2019	J0180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Agalsidase Beta (Fabrazyme)Effective 07/01/2022 - 06/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-E65E1709CFF1	Jul 1, 2022	J0180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Agalsidase Beta (Fabrazyme)Effective 07/01/2023 - 06/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-837D9055CAD1	Jul 1, 2023	J0180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Agalsidase Beta (Fabrazyme)Effective 08/01/2021 - 06/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-21D3ED2C8A7D	Aug 1, 2021	J0180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Agalsidase Beta (Fabrazyme)Effective 09/01/2020 - 07/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-038937B081DB	Sep 1, 2020	J0180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Agalsidase Beta (Fabrazyme)Effective 10/01/2019 - 08/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-72C555A53815	Oct 1, 2019	J0180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aldurazyme (laronidase)PayerPolicy · EVICORE-MEDICAL_DRUG-1543FAB8D106	Not recorded	J1931Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aldurazyme (laronidase)Effective 06/01/2024 - 05/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-8E01D5F95260	Jun 1, 2024	J1931Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aldurazyme (laronidase)Effective 06/01/2025 - 05/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-3D99CF33847A	Jun 1, 2025	J1931Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alemtuzumab (Lemtrada)Effective 01/01/2019 - 05/31/2019PayerPolicy · EVICORE-MEDICAL_DRUG-F8C17997CAD0	Jan 1, 2019	J0202Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alemtuzumab (Lemtrada)Effective 02/01/2023 - 05/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-43F833FE5C92	Feb 1, 2023	J0202Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alemtuzumab (Lemtrada)Effective 03/01/2022 - 01/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-6F8F1F52EAF1	Mar 1, 2022	J0202Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alemtuzumab (Lemtrada)Effective 04/01/2021 - 02/28/2022PayerPolicy · EVICORE-MEDICAL_DRUG-3B1847C1ED9B	Apr 1, 2021	J0202Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alemtuzumab (Lemtrada)Effective 05/01/2020 - 03/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-0768B137C2B2	May 1, 2020	J0202Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alemtuzumab (Lemtrada)Effective 06/01/2019 - 04/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-8B06B3901169	Jun 1, 2019	J0202Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alemtuzumab (Lemtrada)Effective 06/01/2023 - 04/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-BB14064F4F24	Jun 1, 2023	J0202Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alglucosidase Alfa (Lumizyme)Effective 01/01/2019 - 09/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-97F92EAFF929	Jan 1, 2019	J0221Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alglucosidase Alfa (Lumizyme)Effective 07/01/2022 - 06/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-7C2248DA3A9C	Jul 1, 2022	J0221Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alglucosidase Alfa (Lumizyme)Effective 07/01/2023 - 06/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-60E18760A484	Jul 1, 2023	J0221Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alglucosidase Alfa (Lumizyme)Effective 08/01/2021 - 06/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-FBD6D6D37DC5	Aug 1, 2021	J0221Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alglucosidase Alfa (Lumizyme)Effective 09/01/2020 - 07/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-0964231BFA6F	Sep 1, 2020	J0221Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alglucosidase Alfa (Lumizyme)Effective 10/01/2019 - 08/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-B749D2FA1C2E	Oct 1, 2019	J0221Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira)Effective 01/01/2019 - 05/31/2019PayerPolicy · EVICORE-MEDICAL_DRUG-5B4C55D2DB06	Jan 1, 2019	J0256Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0257Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira)Effective 04/01/2019 - 04/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-F3672F5C0778	Apr 1, 2019	J0256Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0257Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira)Effective 04/01/2022 - 03/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-3CC85590913E	Apr 1, 2022	J0256Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0257Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.