EviCore by Evernorth prior authorization codes, page 8 | 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

351–400 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
Imiglucerase (Cerezyme)PayerPolicy · EVICORE-MEDICAL_DRUG-92A430DA7054	Jan 1, 2019	J1786Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.
Imiglucerase (Cerezyme)PayerPolicy · EVICORE-MEDICAL_DRUG-DF08C3C740CB	Aug 1, 2020	J1786Inferred from policy title

Immune Globulin Intramuscular Injection (GamaSTAN)PayerPolicy · EVICORE-MEDICAL_DRUG-42399122F8EF	Jun 1, 2017	J1460Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1560Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Immune Globulin Intramuscular Injection (GamaSTAN)PayerPolicy · EVICORE-MEDICAL_DRUG-797B273A853B	Mar 1, 2019	J1460Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1560Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Immune Globulin Intramuscular Injection (GamaSTAN)PayerPolicy · EVICORE-MEDICAL_DRUG-C6FCE386D099	Nov 1, 2019	J1460Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1560Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Inclisiran Subcutaneous Injection (Leqvio)PayerPolicy · EVICORE-MEDICAL_DRUG-4DD78E582C14	May 1, 2022	J1306Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Inclisiran Subcutaneous Injection (Leqvio)PayerPolicy · EVICORE-MEDICAL_DRUG-C7A13A7626A8	Apr 1, 2023	J1306Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

IncobotulinumtoxinA (Xeomin)PayerPolicy · EVICORE-MEDICAL_DRUG-1855E0613E56	Sep 1, 2019	J0588Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

IncobotulinumtoxinA (Xeomin)PayerPolicy · EVICORE-MEDICAL_DRUG-3EC1B356DA97	Dec 1, 2018	J0588Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

IncobotulinumtoxinA (Xeomin)PayerPolicy · EVICORE-MEDICAL_DRUG-AFBE9852907B	Aug 1, 2022	J0588Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

IncobotulinumtoxinA (Xeomin)PayerPolicy · EVICORE-MEDICAL_DRUG-E50DA1D72CEB	Oct 1, 2020	J0588Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

IncobotulinumtoxinA (Xeomin)PayerPolicy · EVICORE-MEDICAL_DRUG-F4F0C92BAD2A	Sep 1, 2021	J0588Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Inebilizumab-cdon (Uplizna)PayerPolicy · EVICORE-MEDICAL_DRUG-A49AE672831E	Nov 1, 2020	J1823Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Inebilizumab-cdon (Uplizna) InjectionPayerPolicy · EVICORE-MEDICAL_DRUG-0B7E9ABF93DD	Feb 1, 2022	J1823Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Inebilizumab-cdon (Uplizna) InjectionPayerPolicy · EVICORE-MEDICAL_DRUG-4C356F4B4DE9	Jan 1, 2023	J1823Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Inebilizumab-cdon (Uplizna) InjectionPayerPolicy · EVICORE-MEDICAL_DRUG-EFCCE4E7C974	Oct 1, 2021	J1823Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis, Avsola, Infliximab) Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-D392A7C0B1E1	Dec 1, 2024	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5121Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis, Avsola, Infliximab)_Non-oncPayerPolicy · EVICORE-MEDICAL_DRUG-40175DE21FA8	Sep 1, 2023	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5121Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis, Avsola, Infliximab)_Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-2393B54C1389	Jan 1, 2024	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5121Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis, Avsola)PayerPolicy · EVICORE-MEDICAL_DRUG-144F2BE7CAD4	Nov 1, 2022	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5121Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis, Avsola)PayerPolicy · EVICORE-MEDICAL_DRUG-484AF98B2482	Feb 1, 2021	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5121Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis, Avsola)PayerPolicy · EVICORE-MEDICAL_DRUG-E15A5D4ED635	May 1, 2021	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5121Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis, Avsola)PayerPolicy · EVICORE-MEDICAL_DRUG-E2875025B9AD	May 1, 2022	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5121Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis)PayerPolicy · EVICORE-MEDICAL_DRUG-4417D3A93DBD	Oct 1, 2019	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis)PayerPolicy · EVICORE-MEDICAL_DRUG-594C5297A166	Oct 1, 2020	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab (Remicade, Inflectra, Renflexis)PayerPolicy · EVICORE-MEDICAL_DRUG-72DA0C002A05	Nov 2, 2018	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Infliximab Intravenous (Remicade, Inflectra, Renflexis, Avsola, Infliximab)PayerPolicy · EVICORE-MEDICAL_DRUG-24A568507D21	Jan 1, 2026	J1745Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5103Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5104Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. Q5121Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Injectafer (ferric carboxymaltose)PayerPolicy · EVICORE-MEDICAL_DRUG-8A68CA47711C	Oct 1, 2024	J1439Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Injectafer (ferric carboxymaltose)PayerPolicy · EVICORE-MEDICAL_DRUG-C0EDB4D9356E	Not recorded	J1439Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Injectafer (ferric carboxymaltose)PayerPolicy · EVICORE-MEDICAL_DRUG-FFBF9E580E48	Sep 1, 2025	J1439Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Intravenous Immune Globulins (Alyglo, Asceniv, Bivigam, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen, Yimmugo)PayerPolicy · EVICORE-MEDICAL_DRUG-3F46BF993235	Dec 1, 2024	J1459Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1552Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1553Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1554Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1556Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1557Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1561Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1566Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1568Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1569Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1576Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Intravenous Immune Globulins (Alyglo, Asceniv, Bivigam, Flebogamma DIF, Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen, Yimmugo)PayerPolicy · EVICORE-MEDICAL_DRUG-F8F4B1FA8AE8	Dec 1, 2025	J1459Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1552Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1553Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1554Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1556Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1557Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1561Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1566Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1568Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1569Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1576Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Intravenous Immune Globulins (Alyglo, Asceniv, Bivigam, Flebogamma, Gammagard Liquid, Gammagard Liquid ERC, Gammagard S/D, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, Privigen, Qivigy, Yimmugo)PayerPolicy · EVICORE-MEDICAL_DRUG-090544F8FF5F	Not recorded	J1459Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1552Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1553Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1554Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1556Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1557Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1561Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1566Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1568Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1569Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1576Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Izervay (avacincaptad pegol intravitreal injection)PayerPolicy · EVICORE-MEDICAL_DRUG-11C7042E46F1	Jan 1, 2024	J2782Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Izervay (avacincaptad pegol intravitreal solution)PayerPolicy · EVICORE-MEDICAL_DRUG-4BF39CD58954	Jan 1, 2026	J2782Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Izervay (avacincaptad pegol intravitreal solution)PayerPolicy · EVICORE-MEDICAL_DRUG-FCCE9DBD47D1	Jan 1, 2025	J2782Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Kisunla (donanemab-azbt)PayerPolicy · EVICORE-MEDICAL_DRUG-82ABF6E97868	Dec 1, 2024	J0175Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Kisunla (donanemab-azbt)PayerPolicy · EVICORE-MEDICAL_DRUG-9A87F1829DED	Dec 1, 2025	J0175Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Kisunla (donanemab-azbt) Medicare AdvantagePayerPolicy · EVICORE-MEDICAL_DRUG-2E4CA9588F39	Jul 1, 2025	J0175Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Lamzede (velmanase alfa-tycv intravenous infusion)PayerPolicy · EVICORE-MEDICAL_DRUG-EF8CF834FB19	Aug 1, 2024	J0217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Lamzede (velmanase alfa-tycv)PayerPolicy · EVICORE-MEDICAL_DRUG-03A1C2DD4959	Jul 1, 2025	J0217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Lamzede (velmanase alfa-tycv)PayerPolicy · EVICORE-MEDICAL_DRUG-1C3E98EDF443	Aug 1, 2023	J0217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Lamzede (velmanase alfa-tycv)PayerPolicy · EVICORE-MEDICAL_DRUG-C1F05BE81CA4	Not recorded	J0217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Lanreotide (Somatuline Depot, generic) InjectionPayerPolicy · EVICORE-MEDICAL_DRUG-D97E8D0CC88E	May 1, 2025	J1930Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1932Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.