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.
101–150 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 |
|---|---|---|
| Burosumab-Twza Injection (Crysvita)Effective 07/01/2021 - 04/30/2022 | Jul 1, 2021 |
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| Burosumab-Twza Injection (Crysvita)Effective 08/01/2019 - 07/31/2020 | Aug 1, 2019 |
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| Burosumab-Twza Injection (Crysvita)Effective 08/01/2020 - 06/30/2021 | Aug 1, 2020 |
|
|---|
| Burosumab-Twza Injection (Crysvita)Effective 11/02/2018 - 07/31/2019 | Nov 2, 2018 |
|
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| C1 Esterase Inhibitor (Berinert)Effective 01/01/2019 - 05/31/2019 | Jan 1, 2019 |
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| C1 Esterase Inhibitor (Berinert)Effective 03/01/2022 - 02/28/2023 | Mar 1, 2022 |
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| C1 Esterase Inhibitor (Berinert)Effective 03/01/2023 - 01/31/2024 | Mar 1, 2023 |
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| C1 Esterase Inhibitor (Berinert)Effective 05/01/2020 - 03/01/2021 | May 1, 2020 |
|
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| C1 Esterase Inhibitor (Berinert)Effective 06/01/2019 - 05/31/2020 | Jun 1, 2019 |
|
|---|
| C1 Esterase Inhibitor (Cinryze)Effective 01/01/2019 - 05/31/2019 | Jan 1, 2019 |
|
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| C1 Esterase Inhibitor (Cinryze)Effective 03/01/2022 - 02/28/2023 | Mar 1, 2022 |
|
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| C1 Esterase Inhibitor (Cinryze)Effective 03/01/2023 - 01/31/2024 | Mar 1, 2023 |
|
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| C1 Esterase Inhibitor (Cinryze)Effective 05/01/2020 - 03/31/2021 | May 1, 2020 |
|
|---|
| C1 Esterase Inhibitor (Ruconest)Effective 01/01/2019 - 05/31/2019 | Jan 1, 2019 |
|
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| C1 Esterase Inhibitor (Ruconest)Effective 03/01/2022 - 02/28/2023 | Mar 1, 2022 |
|
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| C1 Esterase Inhibitor (Ruconest)Effective 03/01/2023 - 01/31/2024 | Mar 1, 2023 |
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| C1 Esterase Inhibitor (Ruconest)Effective 05/01/2020 - 03/31/2021 | May 1, 2020 |
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| C1 Esterase Inhibitor (Ruconest)Effective 06/01/2019 - 04/30/2020 | Jun 1, 2019 |
|
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| Cabenuva (cabotegravir and rilpivirine extended-release injectable suspension) | Not recorded |
|
|---|
| Cabenuva (cabotegravir and rilpivirine extended-release injectable suspension)Effective 05/01/2024 - 04/30/2025 | May 1, 2024 |
|
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| Cabenuva (cabotegravir and rilpivirine extended-release injectable suspension)Effective 05/01/2025 - 04/30/2026 | May 1, 2025 |
|
|---|
| Cabotegravir and Rilpivirine (Cabenuva)Effective 06/01/2021 - 07/31/2022 | Jun 1, 2021 |
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| Cabotegravir and Rilpivirine (Cabenuva)Effective 06/01/2023 - 04/30/2024 | Jun 1, 2023 |
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| Cabotegravir and Rilpivirine (Cabenuva)Effective 08/01/2022 - 05/31/2023 | Aug 1, 2022 |
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| Canakinumab (Ilaris)Effective 06/01/2023 - 04/30/2024 | Jun 1, 2023 |
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| Canakinumab (Ilaris)Effective 07/01/2021 - 06/30/2022 | Jul 1, 2021 |
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| Canakinumab (Ilaris)Effective 07/01/2022 - 05/31/2023 | Jul 1, 2022 |
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| Canakinumab (Ilaris)Effective 08/01/2020 - 06/30/2021 | Aug 1, 2020 |
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| Canakinumab (Ilaris)Effective 09/01/2019 - 07/31/2020 | Sep 1, 2019 |
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| Canakinumab (Ilaris)Effective 11/02/2018 - 08/31/2019 | Nov 2, 2018 |
|
|---|
| Cerezyme (imiglucerase) | Not recorded |
|
|---|
| Cerezyme (imiglucerase)Effective 05/01/2024 - 04/30/2025 | May 1, 2024 |
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| Cerezyme (imiglucerase)Effective 05/01/2025 - 04/30/2026 | May 1, 2025 |
|
|---|
| Cinqair (reslizumab) | Not recorded |
|
|---|
| Cinqair (reslizumab)Effective 03/01/2025 - 03/31/2025 | Apr 1, 2024 |
|
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| Cinqair (reslizumab)Effective 04/01/2025 - 03/31/2025 | Not recorded |
|
|---|
| Cinryze (C1 esterase inhibitor [human]) | Jan 1, 2026 |
|
|---|
| Cinryze (C1 esterase inhibitor [human])Effective 02/01/2024 - 11/30/2024 | Feb 1, 2024 |
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| Cinryze (C1 esterase inhibitor [human])Effective 12/01/2024 - 12/31/2025 | Dec 1, 2024 |
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| Coagadex (coagulation factor X [Human]) | Dec 1, 2025 |
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| Coagadex (coagulation factor X [Human])Effective 03/01/2025 - 11/30/2025 | Nov 1, 2024 |
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|---|
| Coagulation Factor VIIa (recombinant)-jncw [Sevenfact]Effective 02/01/2021 - 11/30/2021 | Feb 1, 2021 |
|
|---|
| Collagenase Clostridium Histolyticum (Xiaflex)Effective 01/01/2019 - 06/30/2019 | Jan 1, 2019 |
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| Collagenase clostridium histolyticum (Xiaflex)Effective 04/01/2022 - 03/31/2023 | Apr 1, 2022 |
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| Collagenase clostridium histolyticum (Xiaflex)Effective 04/01/2023 - 02/29/2024 | Apr 1, 2023 |
|
|---|
| Collagenase clostridium histolyticum (Xiaflex)Effective 05/01/2021 - 03/31/2022 | May 1, 2021 |
|
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| Collagenase clostridium histolyticum (Xiaflex)Effective 06/01/2020 - 04/30/2021 | Jun 1, 2020 |
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| Collagenase clostridium histolyticum (Xiaflex)Effective 07/01/2019 - 05/31/2020 | Jul 1, 2019 |
|
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| Corifact (factor XIII concentrate [human]) Tretten (coagulation factor XIII A-subunit [recombinant])Effective 03/01/2025 - 11/30/2025 | Nov 1, 2024 |
|---|
| Cosentyx (secukinumab) IntravenousEffective 08/01/2024 - 07/31/2025 | Aug 1, 2024 |
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