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.
501–550 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 |
|---|---|---|
| Ocrelizumab (Ocrevus) | Jan 1, 2019 |
|
| Ocrelizumab (Ocrevus) | Feb 1, 2023 |
|
| Ocrelizumab (Ocrevus) | Mar 1, 2022 |
|
|---|
| Ocrelizumab (Ocrevus) | Jun 1, 2019 |
|
|---|
| Ocrelizumab (Ocrevus) | Jun 1, 2023 |
|
|---|
| Ocrelizumab (Ocrevus) | Apr 1, 2021 |
|
|---|
| Ocrevus (ocrelizumab) | May 1, 2024 |
|
|---|
| Ocrevus (ocrelizumab) Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) | Feb 1, 2026 |
|---|
| Ocrevus (ocrelizumab) Ocrevus Zunovo (ocrelizumab and hyaluronidase-ocsq) | Feb 1, 2025 |
|---|
| Octreotide acetate injection (Sandostatin LAR Depot, Sandostatin) | Aug 1, 2020 |
|---|
| Octreotide acetate injection (Sandostatin LAR Depot, Sandostatin) | Sep 1, 2019 |
|---|
| Octreotide acetate injection (Sandostatin LAR Depot, Sandostatin) | Jan 1, 2019 |
|---|
| Octreotide Acetate Long-acting Products (Sandostatin LAR Depot, generic) | May 1, 2025 |
|---|
| Octreotide Acetate Long-acting Products (Sandostatin LAR Depot, generic) - non-oncology | Not recorded |
|---|
| Octreotide Products (Sandostatin, Sandostatin LAR) | Jul 1, 2021 |
|
|---|
| Octreotide Products (Sandostatin, Sandostatin LAR) | Jun 1, 2022 |
|
|---|
| Octreotide Products (Sandostatin, Sandostatin LAR) | Jun 1, 2023 |
|
|---|
| Olipudase Alfa-rpcp (Xenpozyme) | Jan 1, 2023 |
|
|---|
| Omalizumab (Xolair) | Aug 1, 2019 |
|
|---|
| Omalizumab (Xolair) | Jan 1, 2019 |
|
|---|
| Omalizumab (Xolair) | Jul 1, 2020 |
|
|---|
| Omalizumab (Xolair) | May 1, 2022 |
|
|---|
| Omalizumab (Xolair) | Jun 1, 2021 |
|
|---|
| Omalizumab (Xolair) | May 1, 2023 |
|
|---|
| Onpattro (patisiran) | Aug 1, 2025 |
|
|---|
| Onpattro (patisiran) | Not recorded |
|
|---|
| Onpattro (patisiran) | Oct 1, 2024 |
|
|---|
| Onpattro (Patisiran) | Feb 1, 2023 |
|
|---|
| Onpattro (Patisiran) | Sep 1, 2023 |
|
|---|
| Orencia (abatacept) | Aug 1, 2023 |
|
|---|
| Orencia (abatacept) | Jul 1, 2024 |
|
|---|
| Orencia Intravenous (abatacept) | Aug 1, 2025 |
|
|---|
| Orencia Intravenous (abatacept) | Not recorded |
|
|---|
| Oxlumo (lumasiran) Injection | Not recorded |
|
|---|
| Oxlumo (lumasiran) Injection | Not recorded |
|
|---|
| Oxlumo (lumasiran) Injection | Apr 1, 2024 |
|
|---|
| Pasireotide injection (Signifor LAR) | Aug 1, 2020 |
|
|---|
| Pasireotide injection (Signifor LAR) | Jul 1, 2021 |
|
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| Pasireotide injection (Signifor LAR) | Jan 1, 2019 |
|
|---|
| Pasireotide injection (Signifor LAR) | Sep 1, 2019 |
|
|---|
| Pasireotide injection (Signifor LAR) | Jun 1, 2022 |
|
|---|
| Patisiran (Onpattro) | Jul 1, 2020 |
|
|---|
| Patisiran (Onpattro) | Nov 1, 2022 |
|
|---|
| Patisiran (Onpattro) | Dec 1, 2018 |
|
|---|
| Patisiran (Onpattro) | Aug 1, 2019 |
|
|---|
| Patisiran (Onpattro) | Jul 1, 2021 |
|
|---|
| Pegfilgrastim injection (Neulasta) | Dec 15, 2017 |
|
|---|
| Pegloticase (Krystexxa) | Mar 1, 2022 |
|
|---|
| Pegloticase (Krystexxa) | Apr 1, 2021 |
|
|---|
| Pegloticase (Krystexxa) | Mar 1, 2023 |
|
|---|