Medical Specialty Drug Program—Non-oncology

Effective March 1, 2025, EviCore manages the 1199SEIU Benefit Funds’ Medical Specialty Drug Prior Authorization Program. EviCore performs prior authorizations for certain medical drugs that are bought, billed and administered in an outpatient setting or gene therapies in an inpatient setting. Providers must contact EviCore for prior authorization before administering specialty drugs to their 1199SEIU patients.

In addition to prior authorization, EviCore reviews all medical specialty drug procedure claims for coding accuracy and medical necessity. We urge you to update your claims submission systems and coding practices to avoid payment delays or unnecessary denials.

If you receive an adverse payment decision as a result of EviCore’s code policies, you may submit a request for claim review directly to EviCore. You should fax requests to (844) 545-9214 or mail requests to EviCore healthcare, 400 Buckwalter Place Blvd., Bluffton, SC 29910. Include a copy of the claim, EviCore correspondence, information about the determination to be reviewed and any pertinent documentation to support your request for claim review.

How to Request Prior Authorization for Medical Specialty Drugs Non-oncology Services

• Online: If you have an EviCore provider account, or once you create one for free, visit EviCore's website and log in. You may be able to receive an immediate authorization if your patient meets the coverage criteria.
• By phone: Call EviCore toll-free at (888) 910-1199, Monday through Friday, from 7:00 am to 7:00 pm in all time zones.
• For urgent requests: If services are required in less than 48 hours due to medically urgent conditions, please call EviCore toll-free at (888) 910-1199 for expedited authorization reviews. Be sure to tell the EviCore representative that the authorization is for medically urgent care.

Note: EviCore will not accept initial authorization requests by fax.

If you have any questions about this program, please contact your provider representative or visit the EviCore 1199SEIU Funds Implementation Resources page.

Additional Resources

• EviCore Specialty Drug Quick Reference Guide »
  A one-page guide with useful information, including how to submit a prior authorization request and key contacts.
• Medical Specialty Drug Prior Authorization Program FAQs »