EviCore by Evernorth prior authorization codes, page 5 | 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

201–250 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
Eculizumab (Soliris)Effective 02/01/2023 - 01/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-0C31232CF3F8	Feb 1, 2023	J1299Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.
Eculizumab (Soliris)Effective 03/01/2020 - 03/14/2021PayerPolicy · EVICORE-MEDICAL_DRUG-02D93E0017BA	Mar 1, 2020	J1299Inferred from policy title

Eculizumab (Soliris)Effective 03/15/2021 - 01/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-E1B44E9FD2BD	Mar 15, 2021	J1299Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eculizumab (Soliris)Effective 07/01/2019 - 02/29/2020PayerPolicy · EVICORE-MEDICAL_DRUG-472DBF0D6850	Jul 1, 2019	J1299Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eculizumab Products (Soliris, Bkemv, Epysqli)PayerPolicy · EVICORE-MEDICAL_DRUG-42D804718709	Not recorded	J1299Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5151Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eculizumab Products (Soliris, Bkemv, Epysqli)Effective 07/01/2025 - 06/30/2026PayerPolicy · EVICORE-MEDICAL_DRUG-F1C58570A402	Jul 1, 2025	J1299Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5151Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Edaravone Injection (Radicava)Effective 02/01/2023 - 01/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-642185D91C7E	Feb 1, 2023	J1301Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Edaravone Injection (Radicava)Effective 03/01/2022 - 01/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-28C3F46748D1	Mar 1, 2022	J1301Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Edaravone Injection (Radicava)Effective 03/09/2018 - 08/14/2018PayerPolicy · EVICORE-MEDICAL_DRUG-789AD10A0DFB	Mar 9, 2018	J1301Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Edaravone Injection (Radicava)Effective 04/01/2021 - 02/28/2022PayerPolicy · EVICORE-MEDICAL_DRUG-8F628F99850D	Apr 1, 2021	J1301Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Edaravone Injection (Radicava)Effective 05/01/2020 - 03/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-9253F0E205DE	May 1, 2020	J1301Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Edaravone Injection (Radicava)Effective 08/15/2018 - 05/31/2019PayerPolicy · EVICORE-MEDICAL_DRUG-DC472F8C9175	Aug 15, 2018	J1301Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Edaravone Intravenous (Radicava, generic)PayerPolicy · EVICORE-MEDICAL_DRUG-49F267E0B441	Oct 1, 2025	J1301Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Efgartigimod (Vyvgart)Effective 04/01/2022 - 09/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-DD815D01EAD7	Apr 1, 2022	J9332Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Efgartigimod (Vyvgart)Effective 10/01/2022 - 08/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-8199009D1760	Oct 1, 2022	J9332Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Efgartigimod alfa products (Vyvgart-Vyvgart Hytrulo)Effective 12/01/2023 - 11/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-C764865C3676	Dec 1, 2023	J9332Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J9334Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elaprase (idursulfase)Effective 06/01/2024 - 05/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-EAF21008FE08	Jun 1, 2024	J1743Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elaprase (idursulfase)Effective 06/01/2025 - 05/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-07219320B549	Jun 1, 2025	J1743Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elelyso (taliglucerase alfa)PayerPolicy · EVICORE-MEDICAL_DRUG-387E452C5E84	Not recorded	J3060Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elelyso (taliglucerase alfa)Effective 05/01/2024 - 04/30/2025PayerPolicy · EVICORE-MEDICAL_DRUG-F0333ED4B69F	May 1, 2024	J3060Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elelyso (taliglucerase alfa)Effective 05/01/2025 - 04/30/2026PayerPolicy · EVICORE-MEDICAL_DRUG-27D20C60198D	May 1, 2025	J3060Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elfabrio (pegunigalsidase alfa intravenous infusion)Effective 07/01/2024 - 06/30/2025PayerPolicy · EVICORE-MEDICAL_DRUG-BF5AA970DEA4	Jul 1, 2024	J2508Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elfabrio (pegunigalsidase alfa)PayerPolicy · EVICORE-MEDICAL_DRUG-C8A707AB103D	Not recorded	J2508Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elfabrio (pegunigalsidase alfa)Effective 07/01/2025 - 06/30/2026PayerPolicy · EVICORE-MEDICAL_DRUG-45F73198015A	Jul 1, 2025	J2508Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elfabrio (pegunigalsidase)Effective 10/01/2023 - 06/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-415BA8C97175	Oct 1, 2023	J2508Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elosulfase Alfa (Vimizim)Effective 01/01/2019 - 09/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-D38978416928	Jan 1, 2019	J1322Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elosulfase Alfa (Vimizim)Effective 07/01/2022 - 06/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-0344C1E3B4CA	Jul 1, 2022	J1322Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elosulfase Alfa (Vimizim)Effective 07/01/2023 - 05/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-BFF746B5C476	Jul 1, 2023	J1322Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elosulfase Alfa (Vimizim)Effective 08/01/2021 - 06/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-A4A8BC8A0B3B	Aug 1, 2021	J1322Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Elosulfase Alfa (Vimizim)Effective 09/01/2020 - 07/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-F1756CF54905	Sep 1, 2020	J1322Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Enjaymo (sutimlimab-jome)PayerPolicy · EVICORE-MEDICAL_DRUG-AE24A3F7A518	Nov 1, 2025	J1302Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Enjaymo (sutimlimab-jome)Effective 11/01/2023 - 10/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-F3A4E62734A5	Nov 1, 2023	J1302Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Enjaymo (sutimlimab-jome)Effective 11/01/2024 - 10/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-F2136114846A	Nov 1, 2024	J1302Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Entyvio Intravenous (vedolizumab)PayerPolicy · EVICORE-MEDICAL_DRUG-08D26F25D2A0	Not recorded	J3380Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Entyvio Intravenous (vedolizumab)Effective 06/01/2024 - 05/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-1B6839385B49	Jun 1, 2024	J3380Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Entyvio Intravenous (vedolizumab)Effective 06/01/2025 - 05/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-1B5A9A6E0A63	Jun 1, 2025	J3380Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoetin alfa (Epogen, Procrit, Retacrit)Effective 10/01/2022 - 09/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-5612A423A106	Oct 1, 2022	J0885Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q4081Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5105Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5106Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoetin alfa (Epogen, Procrit, Retacrit)Effective 11/01/2021 - 09/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-C334FBF6D7DB	Nov 1, 2021	J0885Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q4081Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5105Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5106Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoetin alfa (Epogen, Procrit)Effective 11/01/2019 - 11/30/2020PayerPolicy · EVICORE-MEDICAL_DRUG-6BF7E1112FA7	Nov 1, 2019	J0885Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q4081Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoetin alfa (Epogen, Procrit)Effective 12/01/2018 - 10/31/2019PayerPolicy · EVICORE-MEDICAL_DRUG-02179AAFABE4	Dec 1, 2018	J0885Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q4081Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoetin alfa (Epogen, Procrit)Effective 12/01/2020 - 10/31/2021PayerPolicy · EVICORE-MEDICAL_DRUG-CBDB37B1C67B	Dec 1, 2020	J0885Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q4081Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epogen, Procrit, or Retacrit (epoetin alfa) Non-oncologyEffective 10/01/2023 - 09/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-C6CDE8CFE7EF	Oct 1, 2023	J0885Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q4081Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5105Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5106Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epogen, Procrit, Retacrit (epoetin alfa) Injection Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-B3B872C20E2F	Oct 1, 2025	J0885Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q4081Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5105Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5106Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epogen, Procrit, Retacrit (epoetin alfa) Injection Non-oncologyEffective 10/01/2024 - 09/30/2025PayerPolicy · EVICORE-MEDICAL_DRUG-933B975DC366	Oct 1, 2024	J0885Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q4081Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5105Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5106Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epogen, Procrit, Retacrit (epoetin alfa) Injection Non-oncologyEffective 10/01/2026PayerPolicy · EVICORE-MEDICAL_DRUG-98D845C4B804	Not recorded	J0885Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q4081Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5105Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5106Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoprostenol (Flolan, Veletri)Effective 01/01/2019 - 06/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-269E63DAD41F	Jan 1, 2019	J1325Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoprostenol (Flolan, Veletri)Effective 04/01/2022 - 03/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-107F3FD29A94	Apr 1, 2022	J1325Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoprostenol (Flolan, Veletri)Effective 04/01/2023 - 02/29/2024PayerPolicy · EVICORE-MEDICAL_DRUG-4471008DD1FA	Apr 1, 2023	J1325Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoprostenol (Flolan, Veletri)Effective 05/01/2021 - 03/31/2022PayerPolicy · EVICORE-MEDICAL_DRUG-A71BFE2059F6	May 1, 2021	J1325Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.