EviCore by Evernorth prior authorization codes, page 4 | 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

151–200 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
Cosentyx Intravenous (secukinumab)PayerPolicy · EVICORE-MEDICAL_DRUG-42E469CA5D41	Not recorded	J3247Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.
Cosentyx Intravenous (secukinumab)Effective 03/01/2024 - 07/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-0CD06C9EBB1D	Mar 1, 2024	J3247Inferred from policy title

Cosentyx Intravenous (secukinumab)Effective 08/01/2025 - 07/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-DA440E22CBB7	Aug 1, 2025	J3247Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Crizanlizumab-tmca (Adakveo)Effective 02/01/2023 - 01/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-0F6B952D4AF9	Feb 1, 2023	J0791Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Crizanlizumab-tmca (Adakveo)Effective 03/01/2020 - 03/14/2021PayerPolicy · EVICORE-MEDICAL_DRUG-570FFFF54F71	Mar 1, 2020	J0791Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Crizanlizumab-tmca (Adakveo)Effective 03/01/2022 - 01/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-98ED75133B72	Mar 1, 2022	J0791Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Crizanlizumab-tmca (Adakveo)Effective 03/15/2021 - 02/28/2022PayerPolicy · EVICORE-MEDICAL_DRUG-F261BE35CCD9	Mar 15, 2021	J0791Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Crysvita (burosumab-twza) Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-94E6B75AA108	Not recorded	J0584Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Crysvita (burosumab-twza) Non-OncologyEffective 04/01/2025 - 03/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-56A3D4D58CD0	Not recorded	J0584Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Crysvita (burosumab-twza)Effective 04/01/2024 - 02/28/2025PayerPolicy · EVICORE-MEDICAL_DRUG-B3FEEB46E8D4	Apr 1, 2024	J0584Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Darbepoetin Alfa (Aranesp)Effective 10/01/2022 - 09/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-85BC6927CC13	Oct 1, 2022	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.

Darbepoetin Alfa (Aranesp)Effective 11/01/2019 - 11/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-A89A15F5C964	Nov 1, 2019	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.

Darbepoetin Alfa (Aranesp)Effective 11/01/2021 - 09/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-B417527FD7CC	Nov 1, 2021	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.

Darbepoetin Alfa (Aranesp)Effective 12/01/2018 - 10/31/2019PayerPolicy · EVICORE-MEDICAL_DRUG-287EFAEFEDD4	Dec 1, 2018	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.

Darbepoetin Alfa (Aranesp)Effective 12/01/2020 - 10/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-1D6DB0626004	Dec 1, 2020	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.

Daxxify (daxibotulinumtoxinA-lanm)PayerPolicy · EVICORE-MEDICAL_DRUG-0F6ACA52F126	Not recorded	J0589Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Daxxify (daxibotulinumtoxinA-lanm)Effective 01/01/2024 - 07/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-6D4C5E6987A3	Jan 1, 2024	J0589Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Daxxify (daxibotulinumtoxinA-lanm)Effective 08/01/2024 - 07/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-BE17DE7781BB	Aug 1, 2024	J0589Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Daxxify (daxibotulinumtoxinA-lanm)Effective 08/01/2025 - 07/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-0844CABF3475	Aug 1, 2025	J0589Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab (Prolia)Effective 01/01/2020 - 08/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-2CB97F1ABD9C	Jan 1, 2020	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab (Prolia)Effective 07/01/2022 - 06/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-FE7FEC521988	Jul 1, 2022	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab (Prolia)Effective 07/01/2023 - 05/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-24E10B28D659	Jul 1, 2023	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab (Prolia)Effective 08/01/2021 - 06/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-FA3F84D86DED	Aug 1, 2021	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab (Prolia)Effective 09/01/2020 - 07/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-0D19562D3C6D	Sep 1, 2020	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab (Prolia)Effective 12/01/2018 - 12/31/2019PayerPolicy · EVICORE-MEDICAL_DRUG-011C21822CAA	Dec 1, 2018	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab Products (Prolia, Jubbonti, Stoboclo, Conexxence, Bildyos, Ospomyv, Bosaya, Enoby, Osvyrti) Non-oncologyEffective 10/01/2026PayerPolicy · EVICORE-MEDICAL_DRUG-419F2FD5372F	Not recorded	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5136Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5157Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5158Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5162Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab Products (Prolia, Jubbonti, Stoboclo, Conexxence, Bildyos, Ospomyv, Bosaya, Enoby) Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-8A7C48EA6F23	Not recorded	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5136Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5157Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5158Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5162Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab Products (Prolia, Jubbonti, Stoboclo, Conexxence, Bildyos, Ospomyv) Non-oncologyEffective 02/01/2026 - 05/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-369ADDF59C8C	Feb 1, 2026	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5136Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5157Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5158Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5162Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab Products (Prolia, Jubbonti, Stoboclo, Conexxence) Non-oncologyEffective 11/01/2025 - 01/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-4C7F4070D9A6	Nov 1, 2025	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5136Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5157Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5158Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab Products (Prolia, Jubbonti, Stoboclo) Non-oncologyEffective 10/01/2025 - 10/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-A72CF16F6D6A	Oct 1, 2025	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5136Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5157Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Denosumab Products (Prolia, Jubbonti) non-oncologyEffective 09/01/2025 - 09/30/2025PayerPolicy · EVICORE-MEDICAL_DRUG-5AAA5015C392	Sep 1, 2025	J0897Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5136Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Dexamethasone Intravitreal Implant (Ozurdex)Effective 12/01/2018 - 10/31/2019PayerPolicy · EVICORE-MEDICAL_DRUG-DFFE551FE9EE	Dec 1, 2018	J7312Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J8540Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Dornase Alfa Inhalation Solution (Pulmozyme)Effective 01/01/2019 - 11/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-AE078A93D612	Jan 1, 2019	J7639Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Dornase Alfa Inhalation Solution (Pulmozyme)Effective 12/01/2019 - 09/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-056CB605FA79	Dec 1, 2019	J7639Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Durysta (bimatoprost implant, for intracameral administration)Effective 07/01/2024 - 06/30/2025PayerPolicy · EVICORE-MEDICAL_DRUG-2559C4CD6126	Jul 1, 2024	J7351Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Durysta (bimatoprost implant, for intracameral administration)Effective 07/01/2025 - 06/30/2026PayerPolicy · EVICORE-MEDICAL_DRUG-34DBA408ECB2	Jul 1, 2025	J7351Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Durysta (bimatoprost implant)Effective 08/01/2023 - 06/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-2DB75574F266	Aug 1, 2023	J7351Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Durysta (bimatoprost intracameral implant)PayerPolicy · EVICORE-MEDICAL_DRUG-A3E42E17C648	Not recorded	J7351Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Dysport (abobotulinumtoxinA)PayerPolicy · EVICORE-MEDICAL_DRUG-1DD2D61373EF	Not recorded	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Dysport (abobotulinumtoxinA)Effective 08/01/2023 - 08/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-E4A02A08DB4D	Aug 1, 2023	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Dysport (abobotulinumtoxinA)Effective 08/01/2025 - 07/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-D72DF22DA5F2	Aug 1, 2025	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Dysport (abobotulinumtoxinA)Effective 09/01/2024 - 07/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-24C3C967F5B6	Sep 1, 2024	J0586Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Ecallantide (Kalbitor)Effective 01/01/2019 - 05/31/2019PayerPolicy · EVICORE-MEDICAL_DRUG-3E81CC42EFE0	Jan 1, 2019	J1290Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Ecallantide (Kalbitor)Effective 03/01/2022 - 02/28/2023PayerPolicy · EVICORE-MEDICAL_DRUG-C56DCE19C954	Mar 1, 2022	J1290Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Ecallantide (Kalbitor)Effective 03/01/2023 - 01/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-634B4CC37F12	Mar 1, 2023	J1290Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Ecallantide (Kalbitor)Effective 04/01/2021 - 02/28/2022PayerPolicy · EVICORE-MEDICAL_DRUG-33B541F54643	Apr 1, 2021	J1290Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Ecallantide (Kalbitor)Effective 05/01/2020 - 03/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-BA202802990F	May 1, 2020	J1290Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Ecallantide (Kalbitor)Effective 06/01/2019 - 04/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-9205A3FE7385	Jun 1, 2019	J1290Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eculizumab (Soliris)Effective 01/01/2019 - 06/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-587963D4EF34	Jan 1, 2019	J1299Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eculizumab (Soliris)Effective 02/01/2022 - 01/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-95D3DA7CC1D0	Feb 1, 2022	J1299Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.