EviCore by Evernorth prior authorization codes, page 9 | 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

401–450 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
Lanreotide (Somatuline Depot, generic) Injection-non oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-E58B58AAC303	Not recorded	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.

Lanreotide (Somatuline Depot)PayerPolicy · EVICORE-MEDICAL_DRUG-2C45658D595A	Sep 1, 2019	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.

Lanreotide (Somatuline Depot)PayerPolicy · EVICORE-MEDICAL_DRUG-3C17BDAC5A05	Jan 1, 2019	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.

Lanreotide (Somatuline Depot)PayerPolicy · EVICORE-MEDICAL_DRUG-5048D7762313	Jun 1, 2022	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.

Lanreotide (Somatuline Depot)PayerPolicy · EVICORE-MEDICAL_DRUG-76B405A8FC0E	Jun 1, 2023	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.

Lanreotide (Somatuline Depot)PayerPolicy · EVICORE-MEDICAL_DRUG-E04A56B9E3AD	Jul 1, 2021	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.

Lanreotide (Somatuline Depot)PayerPolicy · EVICORE-MEDICAL_DRUG-E97211B4838B	Aug 1, 2020	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.

Leqembi (lecanemab-irmb)PayerPolicy · EVICORE-MEDICAL_DRUG-0A317AA4399C	May 1, 2025	J0174Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leqembi (lecanemab-irmb)PayerPolicy · EVICORE-MEDICAL_DRUG-2E86EEC20B94	May 1, 2024	J0174Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leqembi (lecanemab-irmb)PayerPolicy · EVICORE-MEDICAL_DRUG-BFBBA4DF427A	Not recorded	J0174Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leqvio (inclisiran subcutaneous injection)PayerPolicy · EVICORE-MEDICAL_DRUG-272B5A83AA13	Sep 1, 2024	J1306Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leqvio (inclisiran subcutaneous injection)PayerPolicy · EVICORE-MEDICAL_DRUG-8CD2FD92B9A2	Not recorded	J1306Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leqvio (inclisiran subcutaneous injection)PayerPolicy · EVICORE-MEDICAL_DRUG-A457DB55DE72	Sep 1, 2025	J1306Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leqvio (inclisiran subcutaneous injection)PayerPolicy · EVICORE-MEDICAL_DRUG-E814EEC48B04	Feb 1, 2026	J1306Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leuprolide Acetate (Fensolvi, Lupron Depot- PED, Lupron Depot)PayerPolicy · EVICORE-MEDICAL_DRUG-0D9DE78E57CD	Dec 1, 2022	J1950Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1951Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1954Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J9217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leuprolide Acetate (Fensolvi, Lupron Depot- PED, Lupron Depot)PayerPolicy · EVICORE-MEDICAL_DRUG-63C97D7E6D85	Jan 1, 2022	J1950Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1951Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1954Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J9217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leuprolide Acetate (Fensolvi, Lupron Depot- PED, Lupron Depot)PayerPolicy · EVICORE-MEDICAL_DRUG-F72A2655EAB9	Feb 1, 2021	J1950Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1951Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1954Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J9217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leuprolide acetate (Fensolvi, Lupron Depot-PED, Lupron Depot) Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-1CE6A4748827	Nov 1, 2025	J1950Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1951Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1954Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J9217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leuprolide acetate (Fensolvi, Lupron Depot-PED, Lupron Depot) Non-oncologyPayerPolicy · EVICORE-MEDICAL_DRUG-7DD47D7F3006	Nov 1, 2024	J1950Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1951Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1954Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J9217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leuprolide acetate (Fensolvi, Lupron Depot-PED, Lupron Depot)_Non-oncPayerPolicy · EVICORE-MEDICAL_DRUG-0D687FB0912E	Nov 1, 2023	J1950Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1951Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1954Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J9217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leuprolide acetate (Fensolvi, Lupron Depot-PED, Lupron Depot)_Non-oncPayerPolicy · EVICORE-MEDICAL_DRUG-B25EF227B9F3	Nov 1, 2024	J1950Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1951Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1954Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J9217Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Leuprolide Acetate (Fensolvi)PayerPolicy · EVICORE-MEDICAL_DRUG-B532187E53D7	Sep 1, 2020	J1951Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug. J1954Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Lumizyme (alglucosidase alfa)PayerPolicy · EVICORE-MEDICAL_DRUG-29C76427B3F6	Not recorded	J0221Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Lumizyme (alglucosidase alfa)PayerPolicy · EVICORE-MEDICAL_DRUG-3A963BFFFF18	Jul 1, 2024	J0221Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Lumizyme (alglucosidase alfa)PayerPolicy · EVICORE-MEDICAL_DRUG-CA2912BC6934	Jul 1, 2025	J0221Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Luspatercept-aamt (Reblozyl)PayerPolicy · EVICORE-MEDICAL_DRUG-1EF00D818422	Mar 1, 2020	J0896Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Luspatercept-aamt (Reblozyl)PayerPolicy · EVICORE-MEDICAL_DRUG-3AD34321D127	Jan 1, 2023	J0896Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Luspatercept-aamt (Reblozyl)PayerPolicy · EVICORE-MEDICAL_DRUG-6F8F7E2B123C	Feb 1, 2022	J0896Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.

Luspatercept-aamt (Reblozyl)PayerPolicy · EVICORE-MEDICAL_DRUG-B9BB9E96232E	Mar 15, 2021	J0896Inferred from policy title. Not listed in the policy document; attached because the policy title names the drug.