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.
551–600 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 |
|---|---|---|
| Pegloticase (Krystexxa) | Jun 1, 2019 |
|
| Pegloticase (Krystexxa) | Jan 1, 2019 |
|
| Pegloticase (Krystexxa) | May 1, 2020 |
|
|---|
| PiaSky (crovalimab-akkz) | Nov 1, 2025 |
|
|---|
| PiaSky (crovalimab-akkz) | Nov 1, 2024 |
|
|---|
| Pombiliti (cipaglucosidase alfa-atga) | Jul 1, 2024 |
|
|---|
| Pombiliti (cipaglucosidase alfa-atga) | Feb 1, 2024 |
|
|---|
| Pombiliti (cipaglucosidase alfa-atga) | Jul 1, 2025 |
|
|---|
| Pombiliti (cipaglucosidase alfa-atga) | Not recorded |
|
|---|
| Prolia (denosumab) Non-oncology | Jun 1, 2024 |
|
|---|
| Prolia (denosumab) Non-Oncology | Jul 1, 2025 |
|
|---|
| Purified Cortrophin Gel (repository corticotropin injection) | Feb 1, 2024 |
|
|---|
| Purified Cortrophin Gel (repository corticotropin injection) | Jan 1, 2026 |
|
|---|
| Purified Cortrophin Gel (repository corticotropin injection) | Jan 1, 2025 |
|
|---|
| Qalsody (tofersen intrathecal injection) | Not recorded |
|
|---|
| Qalsody (tofersen intrathecal injection) | Oct 1, 2025 |
|
|---|
| Qalsody (tofersen intrathecal injection) | Oct 1, 2024 |
|
|---|
| Qalsody (tofersen intrathecal injection) Medicare Advantage | Jun 1, 2025 |
|
|---|
| Qalsody (tofersen) | Oct 1, 2023 |
|
|---|
| Radicava (edaravone) | Oct 1, 2024 |
|
|---|
| Radicava (edaravone) | Feb 1, 2024 |
|
|---|
| Ranibizumab (Lucentis Byooviz ) Injection | Oct 1, 2022 |
|---|
| Ranibizumab (Lucentis, Byooviz, and Cimerli) | Jan 1, 2024 |
|
|---|
| Ranibizumab (Lucentis, Byooviz, and Cimerli) Injection | Jan 1, 2026 |
|
|---|
| Ranibizumab (Lucentis, Byooviz, and Cimerli) Injection | Jan 1, 2025 |
|
|---|
| Ranibizumab (Lucentis, Byooviz, and Cimerli) Injection | Jan 1, 2023 |
|
|---|
| Ranibizumab (Lucentis, Byooviz, Nufymco and Cimerli) Injection | Not recorded |
|
|---|
| Ranibizumab (Lucentis) | Dec 1, 2019 |
|
|---|
| Ranibizumab (Lucentis) | Dec 1, 2018 |
|
|---|
| Ranibizumab (Lucentis) | Nov 1, 2020 |
|
|---|
| Ranibizumab (Lucentis) Injection | Oct 1, 2021 |
|
|---|
| Ranibizumab (Lucentis) Injection | Sep 1, 2022 |
|
|---|
| Ranibizumab Implant (Susvimo) | Mar 1, 2022 |
|
|---|
| Ranibizumab Implant (Susvimo) | Mar 1, 2023 |
|
|---|
| Ravulizumab-cwvz (Ultomiris) | May 1, 2019 |
|
|---|
| Ravulizumab-cwvz (Ultomiris) | Mar 1, 2020 |
|
|---|
| Ravulizumab-cwvz (Ultomiris) | Mar 15, 2021 |
|
|---|
| Ravulizumab-cwvz (Ultomiris) | Jan 1, 2022 |
|
|---|
| Ravulizumab-cwvz (Ultomiris) | Feb 1, 2023 |
|
|---|
| Reblozyl (luspatercept-aamt) | Feb 1, 2024 |
|
|---|
| Reblozyl (luspatercept-aamt) | Jan 1, 2026 |
|
|---|
| Reblozyl (luspatercept-aamt) | Jan 1, 2025 |
|
|---|
| Rebyota (fecal microbiota, live-jslm) | Oct 1, 2025 |
|
|---|
| Rebyota (fecal microbiota, live-jslm) | Nov 1, 2023 |
|
|---|
| Rebyota (fecal microbiota, live-jslm) | Not recorded |
|
|---|
| Rebyota (fecal microbiota, live-jslm) | Oct 1, 2024 |
|
|---|
| Reclast (zoledronic acid) | Jun 1, 2025 |
|
|---|
| Reclast (zoledronic acid) | Jun 1, 2024 |
|
|---|
| Reclast (zoledronic acid) Non-oncology | Not recorded |
|
|---|
| Remdesivir (Veklury) | Jun 1, 2023 |
|
|---|