EviCore by Evernorth prior authorization codes, page 2 | Backwork

EviCore by Evernorth prior authorization codes

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.

Policies with prior authorization codes

51–100 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.

EviCore by Evernorth policies and the codes each marks as requiring prior authorization
Policy	Effective	Codes requiring prior authorization
Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira)Effective 04/01/2023 - 03/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-39E37009A343	Apr 1, 2023	J0256Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0257Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira)Effective 05/01/2020 - 05/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-2E0D28D35CDC	May 1, 2020	J0256Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0257Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alpha-1 Proteinase Inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira)Effective 06/01/2021 - 03/31/2022PayerPolicy · EVICORE-MEDICAL_DRUG-BAA7D6DEF69E	Jun 1, 2021	J0256Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0257Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Alprolix, BeneFIX, Idelvion, Ixinity, Rebinyn, Rixubis (coagulation factor IX [recombinant]) AlphaNine SD (coagulation factor IX [plasma-derived]) Profilnine (factor IX complex [plasma-derived])Effective 08/01/2024 - 07/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-83AE1FB39BAA	Aug 1, 2024	J7193Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7194Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7195Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7200Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7201Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7202Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7203Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7213Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Anifrolumab-fnia (Saphnelo)Effective 04/01/2022 - 03/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-4354A5F7FA48	Apr 1, 2022	J0491Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Anifrolumab-fnia (Saphnelo)Effective 04/01/2023 - 02/29/2024PayerPolicy · EVICORE-MEDICAL_DRUG-4B0C7CAAF641	Apr 1, 2023	J0491Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Anifrolumab-fnia (Saphnelo)Effective 12/01/2021 - 03/31/2022PayerPolicy · EVICORE-MEDICAL_DRUG-F9CC6963E966	Dec 1, 2021	J0491Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aralast NP, Glassia, Prolastin-C , and Zemaira (alpha1- proteinase inhibitor [human])Effective 03/01/2025 - 03/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-8595C02C7F16	Mar 1, 2025	J0256Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0257Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aralast NP, Glassia, Prolastin-C , and Zemaira (alpha1- proteinase inhibitor [human])Effective 04/01/2025 - 03/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-3EAEC125AFA9	Not recorded	J0256Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0257Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aralast NP, Glassia, Prolastin-C, and Zemaira (alpha1-proteinase inhibitor [human])PayerPolicy · EVICORE-MEDICAL_DRUG-276987012F29	Not recorded	J0256Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0257Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aranesp (darbepoetin alfa) Injection Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-404BFF45BBE5	Oct 1, 2025	J0881Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0882Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aranesp (darbepoetin alfa) Injection Non-oncologyEffective 10/01/2026PayerPolicy · EVICORE-MEDICAL_DRUG-BDD578A9365A	Not recorded	J0881Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0882Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aranesp (darbepoetin alfa) Non-oncologyEffective 10/01/2023 - 09/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-A22682BFF20A	Oct 1, 2023	J0881Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0882Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Aranesp (darbepoetin alfa) Non-oncologyEffective 10/01/2024 - 02/28/2025PayerPolicy · EVICORE-MEDICAL_DRUG-790A5C589F76	Oct 1, 2024	J0881Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J0882Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Avalglucosidase alfa-ngpt_(Nexviazyme)Effective 07/01/2022 - 06/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-3B318B2754F5	Jul 1, 2022	J0219Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Avalglucosidase alfa-ngpt_(Nexviazyme)Effective 07/01/2023 - 06/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-6BEE8DD6A381	Jul 1, 2023	J0219Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Avalglucosidase alfa-ngpt_(Nexviazyme)Effective 12/01/2021 - 06/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-87DECAF5CF24	Dec 1, 2021	J0219Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Avastin (bevacizumab) Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-64295A6E1DFD	Not recorded	J9035Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Avastin (bevacizumab) Non-oncologyEffective 06/01/2024 - 05/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-C1EEAE78AD46	Jun 1, 2024	J9035Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Avastin (bevacizumab) Non-oncologyEffective 06/01/2025 - 05/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-8CF1BAD755AC	Jun 1, 2025	J9035Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Belimumab (Benlysta)Effective 01/01/2019 - 07/01/2019PayerPolicy · EVICORE-MEDICAL_DRUG-C9DB44D66154	Jan 1, 2019	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Belimumab (Benlysta)Effective 01/01/2023 - 01/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-6AB46FF79B91	Jan 1, 2023	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Belimumab (Benlysta)Effective 04/01/2022 - 12/31/2022PayerPolicy · EVICORE-MEDICAL_DRUG-C56C6E2012CC	Apr 1, 2022	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Belimumab (Benlysta)Effective 05/01/2021 - 03/31/2022PayerPolicy · EVICORE-MEDICAL_DRUG-621BB2C52880	May 1, 2021	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Belimumab (Benlysta)Effective 06/01/2020 - 04/30/2021PayerPolicy · EVICORE-MEDICAL_DRUG-645656E76789	Jun 1, 2020	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Belimumab (Benlysta)Effective 07/01/2019 - 05/31/2020PayerPolicy · EVICORE-MEDICAL_DRUG-7C236BC7EAF1	Jul 1, 2019	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benlysta (belimumab) Intravenous InjectionPayerPolicy · EVICORE-MEDICAL_DRUG-DE0DCB31B4CC	Not recorded	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benlysta (belimumab) Intravenous InjectionEffective 07/01/2024 - 06/30/2025PayerPolicy · EVICORE-MEDICAL_DRUG-F56C6D6BD35D	Jul 1, 2024	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benlysta (belimumab) Intravenous InjectionEffective 07/01/2025 - 06/30/2026PayerPolicy · EVICORE-MEDICAL_DRUG-69C589BE4299	Jul 1, 2025	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benlysta (belimumab)Effective 02/01/2024 - 06/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-448BC3C4DE72	Feb 1, 2024	J0490Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benralizumab (Fasenra)Effective 05/01/2022 - 04/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-8D1E90C52A76	May 1, 2022	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benralizumab (Fasenra)Effective 05/01/2023 - 03/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-B0EFCA2048F7	May 1, 2023	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benralizumab (Fasenra)Effective 06/01/2021 - 04/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-A6873C469661	Jun 1, 2021	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benralizumab (Fasenra)Effective 07/01/2020 - 05/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-89B7047745AE	Jul 1, 2020	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benralizumab (Fasenra)Effective 08/01/2018 - 07/31/2019PayerPolicy · EVICORE-MEDICAL_DRUG-99AD8B722546	Aug 1, 2018	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Benralizumab (Fasenra)Effective 08/01/2019 - 06/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-F58C446DF699	Aug 1, 2019	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Berinert (C1 esterase inhibitor [human])PayerPolicy · EVICORE-MEDICAL_DRUG-5A3192422BCD	Jan 1, 2026	J0597Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Berinert (C1 esterase inhibitor [human])Effective 02/01/2024 - 11/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-0FDC4932F3D5	Feb 1, 2024	J0597Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Berinert (C1 esterase inhibitor [human])Effective 12/01/2024 - 12/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-E3A2154D6707	Dec 1, 2024	J0597Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Bevacizumab (Avastin)Effective 11/01/2020 - 09/30/2021PayerPolicy · EVICORE-MEDICAL_DRUG-10778152A0AB	Nov 1, 2020	J9035Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Bevacizumab (Avastin)Effective 12/01/2018 - 11/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-D509C2FB29BB	Dec 1, 2018	J9035Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Bevacizumab (Avastin)Effective 12/01/2019 - 10/31/2020PayerPolicy · EVICORE-MEDICAL_DRUG-392894837AFC	Dec 1, 2019	J9035Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Bimatoprost Implant (Durysta)Effective 08/01/2021 - 07/31/2022PayerPolicy · EVICORE-MEDICAL_DRUG-233C3B53BCCE	Aug 1, 2021	J7351Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Bimatoprost Implant (Durysta)Effective 08/01/2022 - 07/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-20A7D082B16D	Aug 1, 2022	J7351Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Briumvi (ublituximab-xiij)Effective 05/01/2023 - 04/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-067A03B2118C	May 1, 2023	J2329Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Briumvi (ublituximab-xiiy) Intravenous InjectionPayerPolicy · EVICORE-MEDICAL_DRUG-BF9BD15A069D	Not recorded	J2329Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Briumvi (ublituximab-xiiy) Intravenous InjectionEffective 05/01/2024 - 04/30/2025PayerPolicy · EVICORE-MEDICAL_DRUG-D6C60D72907B	May 1, 2024	J2329Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Briumvi (ublituximab-xiiy) Intravenous InjectionEffective 05/01/2025 - 04/30/2026PayerPolicy · EVICORE-MEDICAL_DRUG-45B1C6130A02	May 1, 2025	J2329Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Burosumab-Twza Injection (Crysvita)Effective 05/01/2022 - 04/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-EC5FDA4A5D39	May 1, 2022	J0584Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Burosumab-Twza Injection (Crysvita)Effective 05/01/2023 - 03/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-E260F5A77692	May 1, 2023	J0584Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.