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.
751–800 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 |
|---|---|---|
| Triptorelin Extended-Release Suspension (Triptodur) | Jan 1, 2022 |
|
| Triptorelin Extended-Release Suspension (Triptodur) | Jul 15, 2018 |
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| Triptorelin Extended-Release Suspension (Triptodur) | Dec 1, 2022 |
|
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| Triptorelin Extended-Release Suspension (Triptodur) | May 1, 2020 |
|
|---|
| Triptorelin Extended-Release Suspension (Triptodur) | Apr 1, 2021 |
|
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| Triptorelin Extended-Release Suspension (Triptodur) - Oscar | Jun 1, 2018 |
|
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| Trogarzo (ibalizumab-uiyk injection) | May 1, 2025 |
|
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| Trogarzo (ibalizumab-uiyk injection) | Not recorded |
|
|---|
| Trogarzo (ibalizumab-uiyk injection) | May 1, 2024 |
|
|---|
| Tysabri (natalizumab) Injection | May 1, 2025 |
|
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| Tysabri (natalizumab) Injection | May 1, 2024 |
|
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| Tzield (teplizumab-mzwv intravenous infusion) | Apr 1, 2023 |
|
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| Tzield (teplizumab-mzwv) | May 1, 2024 |
|
|---|
| Tzield (teplizumab-mzwv) | Not recorded |
|
|---|
| Tzield (teplizumab-mzwv) | Not recorded |
|
|---|
| Tzield (teplizumab-mzwv) | Not recorded |
|
|---|
| Ultomiris (ravulizumab-cwvz) | Feb 1, 2024 |
|
|---|
| Ultomiris (ravulizumab-cwvz) Intravenous Injection | Jan 1, 2025 |
|
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| Ultomiris (ravulizumab-cwvz) Intravenous Injection | Jan 1, 2026 |
|
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| Uplizna (inebilizumab-cdon) injection | Jan 1, 2024 |
|
|---|
| Uplizna (inebilizumab-cdon) injection | Jan 1, 2025 |
|
|---|
| Uplizna (inebilizumab-cdon) Injection | Oct 1, 2025 |
|
|---|
| Uplizna (inebilizumab-cdon) Injection | Not recorded |
|
|---|
| Ustekinumab (Stelara) | Feb 1, 2020 |
|
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| Ustekinumab (Stelara) | Oct 1, 2021 |
|
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| Ustekinumab (Stelara) | Oct 1, 2022 |
|
|---|
| Ustekinumab (Stelara) | Nov 2, 2018 |
|
|---|
| Ustekinumab (Stelara) | Nov 1, 2020 |
|
|---|
| Ustekinumab Intravenous (Stelara , Otulfi, Pyzchiva , Selarsdi, Steqeyma, Wezlana, Yesintek, ustekinumab-ttwe) | Jun 1, 2025 |
|
|---|
| Ustekinumab Intravenous (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Starjemza, Steqeyma, Wezlana, Yesintek, ustekinumab, ustekinumab-ttwe) | Not recorded |
|
|---|
| Ustekinumab Intravenous (Stelara, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Steqeyma , Wezlana, Yesintek , ustekinumab, ustekinumab-ttwe) | Nov 1, 2025 |
|
|---|
| Ustekinumab Intravenous (Stelara, Wezlana) | Apr 1, 2025 |
|---|
| Vabysmo (faricimab-svoa intravitreal) | Jun 1, 2024 |
|
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| Vabysmo (faricimab-svoa intravitreal) | Not recorded |
|
|---|
| Vabysmo (faricimab-svoa intravitreal) | Jun 1, 2025 |
|
|---|
| Vabysmo (faricimab-svoa) | Jan 1, 2024 |
|
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| Vedolizumab (Entyvio) | Aug 1, 2021 |
|
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| Vedolizumab (Entyvio) | Nov 2, 2018 |
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| Vedolizumab (Entyvio) | Aug 1, 2023 |
|
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| Vedolizumab (Entyvio) | Oct 1, 2020 |
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| Vedolizumab (Entyvio) | Oct 1, 2019 |
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| Vedolizumab (Entyvio) | Jul 1, 2022 |
|
|---|
| Veklury (remdesivir) | Aug 1, 2024 |
|
|---|
| Veklury (remdesivir) | Aug 1, 2025 |
|
|---|
| Veklury (remdesivir) | Not recorded |
|
|---|
| Veklury (remdesivir) | May 1, 2024 |
|
|---|
| Verteporfin (Visudyne) | Dec 1, 2018 |
|
|---|
| Vimizim (elosulfase alfa) | Jun 1, 2025 |
|
|---|
| Vimizim (elosulfase alfa) | Not recorded |
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|---|
| Vimizim (elosulfase alfa) | Jun 1, 2024 |
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|---|