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.
451–500 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.
| Policy | Effective | Codes requiring prior authorization |
|---|---|---|
| Mepolizumab (Nucala) | May 1, 2023 |
|
| Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) | Nov 1, 2019 |
|
| Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) | Dec 1, 2020 |
|---|
| Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) | Dec 1, 2018 |
|---|
| Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) Injection | Oct 1, 2022 |
|---|
| Methoxy Polyethylene Glycol-Epoetin Beta (Mircera) Injection | Nov 1, 2021 |
|---|
| Mircera (methoxy polyethylene glycol- epoetin beta) | Oct 1, 2023 |
|---|
| Mircera (methoxy polyethylene glycol-epoetin beta) Injection | Not recorded |
|---|
| Mircera (methoxy polyethylene glycol-epoetin beta) Injection | Nov 1, 2024 |
|---|
| Mircera (methoxy polyethylene glycol-epoetin beta) Injection | Oct 1, 2025 |
|---|
| Mircera(methoxy polyethylene glycol- epoetin beta) | Oct 1, 2024 |
|---|
| Monoferric (ferric derisomaltose) | Sep 1, 2025 |
|
|---|
| Monoferric (ferric derisomaltose) | Oct 1, 2024 |
|
|---|
| Monoferric (ferric derisomaltose) | Not recorded |
|
|---|
| Myobloc (rimabotulinumtoxinB) | Aug 1, 2025 |
|
|---|
| Myobloc (rimabotulinumtoxinB) | Aug 1, 2024 |
|
|---|
| Myobloc (rimabotulinumtoxinB) | Not recorded |
|
|---|
| Myobloc (rimabotulinumtoxinB) | Aug 1, 2023 |
|
|---|
| Naglazyme (galsulfase) | Jun 1, 2024 |
|
|---|
| Naglazyme (galsulfase) | Jun 1, 2025 |
|
|---|
| Naglazyme (galsulfase) | Not recorded |
|
|---|
| Naltrexone (Vivitrol) | Jan 1, 2019 |
|
|---|
| Natalizumab (Tysabri) | May 1, 2020 |
|
|---|
| Natalizumab (Tysabri) | Jun 1, 2023 |
|
|---|
| Natalizumab (Tysabri) | Apr 1, 2021 |
|
|---|
| Natalizumab (Tysabri) | Jan 1, 2019 |
|
|---|
| Natalizumab (Tysabri) | Mar 1, 2022 |
|
|---|
| Natalizumab (Tysabri) | Feb 1, 2023 |
|
|---|
| Natalizumab (Tysabri) | Jul 1, 2019 |
|
|---|
| Natalizumab Products (Tysabri, Tyruko) | Feb 1, 2026 |
|---|
| Nexviazyme (avalglucosidase alfa-ngpt) | Jul 1, 2025 |
|
|---|
| Nexviazyme (avalglucosidase alfa-ngpt) | Jul 1, 2024 |
|
|---|
| Nexviazyme (avalglucosidase alfa-ngpt) | Not recorded |
|
|---|
| NovoSeven RT (coagulation factor VIIa [recombinant]) | Dec 1, 2025 |
|
|---|
| NovoSeven RT (coagulation factor VIIa [recombinant]) | Nov 1, 2024 |
|
|---|
| Nplate (romiplostim) Non-oncology | Not recorded |
|
|---|
| Nplate (romiplostim) Non-oncology | Not recorded |
|
|---|
| Nucala (mepolizumab) | Oct 1, 2025 |
|
|---|
| Nucala (mepolizumab) | Apr 1, 2024 |
|
|---|
| Nucala (mepolizumab) | Not recorded |
|
|---|
| Nucala (mepolizumab) | Not recorded |
|
|---|
| Nucala (mepolizumab) | Apr 1, 2025 |
|
|---|
| Nulibry (fosdenopterin) | Not recorded |
|
|---|
| Nulibry (fosdenopterin) | Aug 1, 2023 |
|
|---|
| Nulibry (fosdenopterin) | Aug 1, 2025 |
|
|---|
| Nulibry (fosdenopterin) | Aug 1, 2024 |
|
|---|
| Nulojix (belatacept) | Mar 1, 2025 |
|
|---|
| Nulojix (belatacept) | Not recorded |
|
|---|
| Obizur (Antihemophilic Factor [Recombinant], Porcine Sequence) | Aug 1, 2025 |
|
|---|
| Obizur (Antihemophilic Factor [Recombinant], Porcine Sequence) | Not recorded |
|
|---|