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.
651–700 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 |
|---|---|---|
| Sevenfact (coagulation factor VIIa [recombinant]-jncw) | Dec 1, 2025 |
|
| Signifor LAR (pasireotide) Injectable Suspension | May 1, 2024 |
|
| Signifor LAR (pasireotide) Injectable Suspension | May 1, 2025 |
|
|---|
| Signifor LAR (pasireotide) Injectable Suspension | Not recorded |
|
|---|
| Signifor LAR (pasireotide) Injectable Suspension | Jun 1, 2023 |
|
|---|
| Simponi Aria (golimumab) | Jan 1, 2026 |
|
|---|
| Simponi Aria (golimumab) | Dec 1, 2024 |
|
|---|
| Simponi Aria (golimumab) | Jan 1, 2024 |
|
|---|
| Simponi Aria (golimumab) | Aug 1, 2023 |
|
|---|
| Skyrizi (risankizumab-rzaa) | May 1, 2023 |
|
|---|
| Skyrizi Intravenous (risankizumab-rzaa) | Jun 1, 2024 |
|
|---|
| Skyrizi Intravenous (risankizumab-rzaa) | Dec 1, 2025 |
|
|---|
| Skyrizi Intravenous (risankizumab-rzaa) | Dec 1, 2024 |
|
|---|
| Soliris (eculizumab) | Jan 1, 2025 |
|
|---|
| Soliris (eculizumab) | Feb 1, 2024 |
|
|---|
| Somatuline Depot (lanreotide injectable) | May 1, 2024 |
|---|
| Spesolimab-sbzo (Spevigo) | Jan 1, 2023 |
|
|---|
| Spevigo (spesolimab-sbzo intravenous infusion) | Jan 1, 2024 |
|
|---|
| Spevigo (spesolimab-sbzo) Intravenous Injection | Jan 1, 2026 |
|
|---|
| Spevigo Intravenous (spesolimab-sbzo intravenous infusion) | Feb 1, 2025 |
|
|---|
| Stelara (ustekinumab) | Dec 1, 2023 |
|
|---|
| Stelara (ustekinumab) | Aug 1, 2024 |
|
|---|
| Stelara (ustekinumab) | Aug 1, 2023 |
|
|---|
| Subcutaneous Immune Globulins (Cutaquig, Cuvitru, Gammagard Liquid, Gammagard Liquid ERC, Gammaked, Gamunex-C, Hizentra, HyQvia, Xembify) | Not recorded |
|
|---|
| Subcutaneous Immune Globulins (Cutaquig, Cuvitru, Gammagard Liquid, Gammaked, Gamunex-C, Hizentra, HyQvia, Xembify) | Dec 1, 2025 |
|
|---|
| Subcutaneous Immune Globulins (Cutaquig, Cuvitru, Hizentra, HyQvia, Xembify, Gammagard Liquid, Gammaked, Gamunex-C) | Dec 1, 2024 |
|
|---|
| Subcutaneous Immune Globulins (Cuvitru, Hizentra, Hyqvia) | Dec 1, 2019 |
|
|---|
| Subcutaneous Immune Globulins (Cuvitru, Hizentra, Hyqvia) | Oct 1, 2022 |
|
|---|
| Subcutaneous Immune Globulins (Cuvitru, Hizentra, Hyqvia) | Oct 1, 2021 |
|
|---|
| Subcutaneous Immune Globulins (Cuvitru, Hizentra, Hyqvia) | Mar 1, 2019 |
|
|---|
| Subcutaneous Immune Globulins (Cuvitru, Hizentra, Hyqvia) | Nov 1, 2020 |
|
|---|
| Sunlenca (lenacapavir) | Jun 1, 2023 |
|
|---|
| Sunlenca (lenacapavir) Injection | May 1, 2025 |
|
|---|
| Sunlenca (lenacapavir) Injection | Not recorded |
|
|---|
| Sunlenca (lenacapavir) Injection | May 1, 2024 |
|
|---|
| Susvimo (ranibizumab intravitreal injection via ocular implant) | Feb 1, 2024 |
|
|---|
| Susvimo (ranibizumab intravitreal injection via ocular implant) | Not recorded |
|
|---|
| Susvimo (ranibizumab intravitreal injection via ocular implant) | Jan 1, 2026 |
|
|---|
| Sutimlimab-jome (Enjaymo) | Nov 1, 2022 |
|
|---|
| Sutimlimab-jome (Enjaymo) | Jul 1, 2022 |
|
|---|
| Syfovre (pegcetacoplan injection) | Jan 1, 2026 |
|
|---|
| Syfovre (pegcetacoplan injection) | Jan 1, 2025 |
|
|---|
| Syfovre (pegcetacoplan) | Jan 1, 2024 |
|
|---|
| Syfovre (pegcetacoplan) | Jul 1, 2023 |
|
|---|
| Taliglucerase alfa (Elelyso) | Sep 1, 2019 |
|
|---|
| Taliglucerase alfa (Elelyso) | Aug 1, 2020 |
|
|---|
| Taliglucerase alfa (Elelyso) | Jun 1, 2023 |
|
|---|
| Taliglucerase alfa (Elelyso) | Jun 1, 2022 |
|
|---|
| Taliglucerase alfa (Elelyso) | Aug 1, 2021 |
|
|---|
| Taliglucerase, Velaglucerasa alfa (Elelyso, VPRIV) | Jan 1, 2019 |
|
|---|