EviCore by Evernorth prior authorization codes, page 6 | 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

251–300 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
Epoprostenol (Flolan, Veletri)Effective 06/01/2020 - 04/30/2021PayerPolicy · EVICORE-MEDICAL_DRUG-84290FF84D91	Jun 1, 2020	J1325Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.
Epoprostenol (Flolan, Veletri)Effective 07/01/2019 - 05/31/2020PayerPolicy · EVICORE-MEDICAL_DRUG-0F6B4620FF9B	Jul 1, 2019	J1325Inferred from policy title

Epoprostenol Injection (Flolan, Veletri, generic)PayerPolicy · EVICORE-MEDICAL_DRUG-5C0D22C1159F	Not recorded	J1325Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Epoprostenol Injection (Flolan, Veletri, generic)Effective 03/01/2025 - 02/28/2026PayerPolicy · EVICORE-MEDICAL_DRUG-7B4ED4DB97E4	Mar 1, 2025	J1325Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eptinezumab-jjmr (Vyepti)Effective 06/01/2022 - 06/30/2023PayerPolicy · EVICORE-MEDICAL_DRUG-45A550F8CE08	Jun 1, 2022	J3032Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eptinezumab-jjmr (Vyepti)Effective 07/01/2021 - 05/31/2022PayerPolicy · EVICORE-MEDICAL_DRUG-067C0109A1B5	Jul 1, 2021	J3032Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eptinezumab-jjmr (Vyepti)Effective 07/01/2023 - 04/30/2024PayerPolicy · EVICORE-MEDICAL_DRUG-856521AF2C32	Jul 1, 2023	J3032Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eptinezumab-jjmr (Vyepti)Effective 08/01/2020 - 06/30/2021PayerPolicy · EVICORE-MEDICAL_DRUG-FFECA2F8D5C1	Aug 1, 2020	J3032Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evenity (romosozumab-aqqg)PayerPolicy · EVICORE-MEDICAL_DRUG-9932CF1E6960	Not recorded	J3111Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evenity (romosozumab-aqqg)Effective 06/01/2024 - 05/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-58775B46A63A	Jun 1, 2024	J3111Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evenity (romosozumab-aqqg)Effective 06/01/2025 - 05/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-317D821281BD	Jun 1, 2025	J3111Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evinacumab-dgnb (Evkeeza)Effective 04/01/2023 - 08/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-319DE97AF0D6	Apr 1, 2023	J1305Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evinacumab-dgnb (Evkeeza)Effective 05/01/2022 - 03/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-4299B92C9D4F	May 1, 2022	J1305Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evinacumab-dgnb (Evkeeza)Effective 06/01/2021 - 04/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-16D234B000C4	Jun 1, 2021	J1305Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evkeeza (evinacumab-dgnb)PayerPolicy · EVICORE-MEDICAL_DRUG-04890B36CCC9	Not recorded	J1305Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evkeeza (evinacumab-dgnb)Effective 02/01/2026 - 08/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-1B1E87BA265E	Feb 1, 2026	J1305Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evkeeza (evinacumab-dgnb)Effective 09/01/2023 - 08/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-004B62A09DFF	Sep 1, 2023	J1305Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evkeeza (evinacumab-dgnb)Effective 09/01/2024 - 08/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-4A01BAE4E57B	Sep 1, 2024	J1305Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Evkeeza (evinacumab-dgnb)Effective 09/01/2025 - 01/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-62C4900E96C4	Sep 1, 2025	J1305Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eylea, Eylea HD (aflibercept) InjectionEffective 01/01/2025 - 04/30/2025PayerPolicy · EVICORE-MEDICAL_DRUG-F9F180BC2B51	Jan 1, 2025	J0177Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Eylea, Eylea HD (aflibercept)Effective 01/01/2024 - 12/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-619D77521A98	Jan 1, 2024	J0177Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Fabrazyme (agalsidase beta)PayerPolicy · EVICORE-MEDICAL_DRUG-D506BA14B28D	Not recorded	J0180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Fabrazyme (agalsidase beta)Effective 07/01/2024 - 06/30/2025PayerPolicy · EVICORE-MEDICAL_DRUG-B7B76B2DB9B1	Jul 1, 2024	J0180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Fabrazyme (agalsidase beta)Effective 07/01/2025 - 06/30/2026PayerPolicy · EVICORE-MEDICAL_DRUG-72A288DEC038	Jul 1, 2025	J0180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Factor XIII Products Corifact (factor XIII concentrate [human]) Tretten (coagulation factor XIII A-subunit [recombinant])PayerPolicy · EVICORE-MEDICAL_DRUG-FB94ADA7F1E7	Dec 1, 2025	J7180Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7181Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Faricimab-svoa (Vabysmo)Effective 03/01/2023 - 12/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-AC964C7B0DA7	Mar 1, 2023	J2777Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Faricimab-svoa (Vabysmo)Effective 06/01/2022 - 07/18/2022PayerPolicy · EVICORE-MEDICAL_DRUG-91AA8AFB6AEB	Jun 1, 2022	J2777Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Fasenra (benralizumab)Effective 04/01/2024 - 08/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-AB2FCCB8C84E	Apr 1, 2024	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Fasenra (benralizumab)Effective 04/01/2025 - 03/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-78429D884CA3	Not recorded	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Fasenra (benralizumab)Effective 09/01/2024 - 03/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-860AE39F0596	Sep 1, 2024	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Fasenra (benralizumab)Effective 10/01/2026PayerPolicy · EVICORE-MEDICAL_DRUG-89ED9491EEA0	Not recorded	J0517Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Feraheme (ferumoxytol)Effective 03/01/2025 - 08/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-E5E7C43AEA46	Oct 1, 2024	Q0138Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q0139Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Feraheme (ferumoxytol)Effective 09/01/2025 - 08/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-2BDF89EEE950	Sep 1, 2025	Q0138Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q0139Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Ferumoxytol Injection (Feraheme, generic)PayerPolicy · EVICORE-MEDICAL_DRUG-02D9620C4CE3	Not recorded	Q0138Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q0139Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Fibrinogen Products (RiaSTAP, Fibryga)PayerPolicy · EVICORE-MEDICAL_DRUG-9D3020ADE894	Not recorded	J7177Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7178Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Fibrinogen Products (RiaSTAP, Fibryga)Effective 12/01/2025 - 04/30/2026PayerPolicy · EVICORE-MEDICAL_DRUG-E7CE64F816C4	Dec 1, 2025	J7177Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J7178Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim (Neupogen , Nivestym, Zarxio, Releuko) Non-oncologyEffective 03/01/2025 - 03/31/2025PayerPolicy · EVICORE-MEDICAL_DRUG-572C414BC769	Mar 1, 2025	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5110Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5125Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim (Neupogen, Nivestrym, Zarxio)Effective 01/01/2021 - 11/30/2021PayerPolicy · EVICORE-MEDICAL_DRUG-6396A696C4B4	Jan 1, 2021	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim (Neupogen, Nivestrym, Zarxio)Effective 12/01/2018 - 11/30/2019PayerPolicy · EVICORE-MEDICAL_DRUG-E6C1500647A8	Dec 1, 2018	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim (Neupogen, Nivestrym, Zarxio)Effective 12/01/2019 - 12/31/2020PayerPolicy · EVICORE-MEDICAL_DRUG-2953706C2E4E	Dec 1, 2019	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim (Neupogen, Nivestrym, Zarxio)Effective 12/01/2021 - 11/30/2022PayerPolicy · EVICORE-MEDICAL_DRUG-1B67883E7F92	Dec 1, 2021	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim (Neupogen, Nivestym, Nypozi, Releuko, Zarxio) Non-oncologyEffective 04/01/2025 - 03/31/2026PayerPolicy · EVICORE-MEDICAL_DRUG-5BA2A7681E27	Apr 1, 2025	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5110Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5125Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5148Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim (Neupogen, Nivestym, Zarxio, Releuko)_Non-oncologyEffective 11/01/2023 - 10/31/2024PayerPolicy · EVICORE-MEDICAL_DRUG-60A342CFB675	Nov 1, 2023	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5110Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5125Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim (Neupogen, Nivestym, Zarxio, Releuko)_Non-oncologyEffective 11/01/2024 - 02/28/2025PayerPolicy · EVICORE-MEDICAL_DRUG-1E8B16785E7D	Nov 1, 2024	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5110Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5125Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim (Neupogen, Nivestym, Zarxio, Releuko)Effective 12/01/2022 - 10/31/2023PayerPolicy · EVICORE-MEDICAL_DRUG-0D5C475A7C00	Dec 1, 2022	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5110Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5125Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim injection (Neupogen)Effective 12/15/2017 - 04/11/2019PayerPolicy · EVICORE-MEDICAL_DRUG-992C99A707E2	Dec 15, 2017	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim Products (Neupogen, Nivestym, Nypozi, Releuko, Zarxio, Filkri) Non-oncologyEffective 10/01/2026PayerPolicy · EVICORE-MEDICAL_DRUG-4E919098646A	Not recorded	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5110Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5125Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5148Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Filgrastim Products (Neupogen, Nivestym, Nypozi, Releuko, Zarxio) Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-A471D001CE8C	Not recorded	J1442Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5101Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5110Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5125Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5148Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Flolan, Veletri (epoprostenol) injectionEffective 03/01/2024 - 02/28/2025PayerPolicy · EVICORE-MEDICAL_DRUG-E22008C56D34	Mar 1, 2024	J1325Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.