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.
301–350 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 |
|---|---|---|
| Fluocinolone Acetonide Intravitreal Implant (Iluvien)Effective 12/01/2018 - 10/31/2019 | Dec 1, 2018 |
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| Fluocinolone Acetonide Intravitreal Implant (Retisert)Effective 12/01/2018 - 10/31/2019 | Dec 1, 2018 |
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| Fosdenopterin (Nulibry)Effective 08/01/2021 - 07/31/2022 | Aug 1, 2021 |
|
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| Fosdenopterin (Nulibry)Effective 08/01/2022 - 07/31/2023 | Aug 1, 2022 |
|
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| Galsulfase (Naglazyme)Effective 01/01/2019 - 09/30/2019 | Jan 1, 2019 |
|
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| Galsulfase (Naglazyme)Effective 07/01/2022 - 06/30/2023 | Jul 1, 2022 |
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| Galsulfase (Naglazyme)Effective 07/01/2023 - 05/31/2024 | Jul 1, 2023 |
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| Galsulfase (Naglazyme)Effective 08/01/2021 - 06/30/2022 | Aug 1, 2021 |
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| Galsulfase (Naglazyme)Effective 09/01/2020 - 07/31/2021 | Sep 1, 2020 |
|
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| Galsulfase (Naglazyme)Effective 10/01/2019 - 08/30/2020 | Oct 1, 2019 |
|
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| Gamifant (emapalumab-lzsg) | Dec 1, 2025 |
|
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| Gazyva (obinutuzumab) Injection Non-oncology | Not recorded |
|
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| Givlaari (givosiran) | Jan 1, 2026 |
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| Givlaari (givosiran)Effective 02/01/2024 - 11/30/2024 | Feb 1, 2024 |
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| Givlaari (givosiran)Effective 12/01/2024 - 12/31/2025 | Dec 1, 2024 |
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| Givosiran (Givlaari)Effective 04/01/2021 - 02/28/2022 | Apr 1, 2021 |
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| Givosiran (Givlaari)Effective 05/01/2020 - 03/31/2021 | May 1, 2020 |
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| Golimumab (Simponi Aria)Effective 02/01/2020 - 10/31/2020 | Feb 1, 2020 |
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| Golimumab (Simponi Aria)Effective 02/01/2021 - 10/01/2021 | Feb 1, 2021 |
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| Golimumab (Simponi Aria)Effective 09/01/2022 - 07/31/2023 | Sep 1, 2022 |
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| Golimumab (Simponi Aria)Effective 10/01/2021 - 08/31/2022 | Oct 1, 2021 |
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| Golimumab (Simponi Aria)Effective 11/01/2020 - 01/31/2021 | Nov 1, 2020 |
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| Golimumab (Simponi Aria)Effective 11/02/2018 - 01/31/2020 | Nov 2, 2018 |
|
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| Hemlibra (emicizumab-kxwh) | Dec 1, 2025 |
|
|---|
| Ibalizumab-uiyk (Trogarzo)Effective 02/01/2020 - 11/30/2020 | Feb 1, 2020 |
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| Ibalizumab-uiyk (Trogarzo)Effective 06/01/2022 - 05/31/2023 | Jun 1, 2022 |
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| Ibalizumab-uiyk (Trogarzo)Effective 06/01/2023 - 04/30/2024 | Jun 1, 2023 |
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| Ibalizumab-uiyk (Trogarzo)Effective 08/01/2018 - 01/31/2020 | Aug 1, 2018 |
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| Ibalizumab-uiyk (Trogarzo)Effective 11/01/2021 - 05/31/2022 | Nov 1, 2021 |
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| Ibalizumab-uiyk (Trogarzo)Effective 12/01/2020 - 10/31/2021 | Dec 1, 2020 |
|
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| Ibandronate Sodium (Boniva)Effective 07/01/2022 - 06/30/2023 | Jul 1, 2022 |
|
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| iDose TR (travoprost intracameral implant) | Not recorded |
|
|---|
| Idursulfase (Elaprase)Effective 01/01/2019 - 09/30/2019 | Jan 1, 2019 |
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| Idursulfase (Elaprase)Effective 07/01/2022 - 06/30/2023 | Jul 1, 2022 |
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| Idursulfase (Elaprase)Effective 07/01/2023 - 05/31/2024 | Jul 1, 2023 |
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| Idursulfase (Elaprase)Effective 08/01/2021 - 06/30/2022 | Aug 1, 2021 |
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| Idursulfase (Elaprase)Effective 09/01/2020 - 07/31/2021 | Sep 1, 2020 |
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| Idursulfase (Elaprase)Effective 10/01/2019 - 08/30/2020 | Oct 1, 2019 |
|
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| Ilaris (canakinumab) | Not recorded |
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| Ilaris (canakinumab)Effective 05/01/2024 - 04/30/2025 | May 1, 2024 |
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| Ilaris (canakinumab)Effective 05/01/2025 - 04/30/2026 | May 1, 2025 |
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| Ilumya (tildrakizumab-asmn) | Not recorded |
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| Ilumya (tildrakizumab-asmn)Effective 07/01/2024 - 06/30/2025 | Jul 1, 2024 |
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| Ilumya (tildrakizumab-asmn)Effective 07/01/2025 - 06/30/2026 | Jul 1, 2025 |
|
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| Imaavy (nipocalimab-aahu intravenous infusion) | Not recorded |
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| Imaavy (nipocalimab-aahu intravenous infusion)Effective 09/01/2025 - 08/31/2026 | Sep 1, 2025 |
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| Imiglucerase (Cerezyme)Effective 01/01/2019 - 08/31/2019 | Jan 1, 2019 |
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| Imiglucerase (Cerezyme)Effective 06/01/2022 - 05/31/2023 | Jun 1, 2022 |
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| Imiglucerase (Cerezyme)Effective 06/01/2023 - 04/30/2024 | Jun 1, 2023 |
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| Imiglucerase (Cerezyme)Effective 07/01/2021 - 05/31/2022 | Jul 1, 2021 |
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