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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 56

CPT code lookup

Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.

Prior authorization codes

Prior authorization codes
CodeDescriptionSource
J0491Injection, anifrolumab-fnia, 1 mgNew Hampshire Precertification List, Pg 234 Original policy
J0517Injection, benralizumab, 1 mgNew Hampshire Precertification List, Pg 234 Original policy
J0558Injection, penicillin G benzathine and penicillin G procaine, 100,000 unitsNew Hampshire Precertification List, Pg 234 Original policy
J0561Injection, penicillin G benzathine, 100,000 unitsNew Hampshire Precertification List, Pg 234 Original policy
J0565Injection, bezlotoxumab, 10 mgNew Hampshire Precertification List, Pg 234 Original policy
J0567Injection, cerliponase alfa, 1 mgNew Hampshire Precertification List, Pg 234 Original policy
J0584Injection, burosumab-twza 1 mgNew Hampshire Precertification List, Pg 234 Original policy
J0585Injection, onabotulinumtoxinA, 1 unitNew Hampshire Precertification List, Pg 234 Original policy
J0586Injection, abobotulinumtoxinA, 5 unitsNew Hampshire Precertification List, Pg 234 Original policy
J0587Injection, rimabotulinumtoxinB, 100 unitsNew Hampshire Precertification List, Pg 235 Original policy
J0588Injection, incobotulinumtoxinA, 1 unitNew Hampshire Precertification List, Pg 235 Original policy
J0589Injection, daxibotulinumtoxina-lanm, 1 unitNew Hampshire Precertification List, Pg 235 Original policy
J0593Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self- administered)New Hampshire Precertification List, Pg 235 Original policy
J0596Injection, C1 esterase inhibitor (recombinant), Ruconest, 10 unitsNew Hampshire Precertification List, Pg 235 Original policy
J0597Injection, C1 esterase inhibitor (human), Berinert, 10 unitsNew Hampshire Precertification List, Pg 235 Original policy
J0598Injection, C1 esterase inhibitor (human), Cinryze, 10 unitsNew Hampshire Precertification List, Pg 235 Original policy
J0599Injection, C1 esterase inhibitor (human), (Haegarda), 10 unitsNew Hampshire Precertification List, Pg 235 Original policy
J0638Injection, canakinumab, 1 mgNew Hampshire Precertification List, Pg 235 Original policy
J0641Injection, levoleucovorin, not otherwise specified, 0.5 mgNew Hampshire Precertification List, Pg 235 Original policy
J0642Injection, levoleucovorin (Khapzory), 0.5 mgNew Hampshire Precertification List, Pg 235 Original policy
J0687Injection, cefazolin sodium (WG Critical Care), not therapeutically equivalent to J0690, 500 mgNew Hampshire Precertification List, Pg 235 Original policy
J0688Injection, cefazolin sodium (Hikma), not therapeutically equivalent to J0690, 500 mgNew Hampshire Precertification List, Pg 235 Original policy
J0689Injection, cefazolin sodium (Baxter), not therapeutically equivalent to J0690, 500 mgNew Hampshire Precertification List, Pg 235 Original policy
J0690Injection, cefazolin sodium, 500 mgNew Hampshire Precertification List, Pg 235 Original policy
J0696Injection, ceftriaxone sodium, per 250 mgNew Hampshire Precertification List, Pg 235 Original policy
J0698Injection, cefotaxime sodium, per gNew Hampshire Precertification List, Pg 235 Original policy
J0717Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)New Hampshire Precertification List, Pg 235 Original policy
J0741Injection, cabotegravir and rilpivirine, 2 mg/3 mgNew Hampshire Precertification List, Pg 235 Original policy
J0743Injection, cilastatin sodium; imipenem, per 250 mgNew Hampshire Precertification List, Pg 235 Original policy
J0744Injection, ciprofloxacin for intravenous infusion, 200 mgNew Hampshire Precertification List, Pg 235 Original policy
J0775Injection, collagenase, clostridium histolyticum, 0.01 mgNew Hampshire Precertification List, Pg 235 Original policy
J0791Injection, crizanlizumab-tmca, 5 mgNew Hampshire Precertification List, Pg 235 Original policy
J0799FDA-approved prescription drug, only for use as HIV pre-exposure prophylaxis (not for use as treatment of HIV), not otherwise classifiedNew Hampshire Precertification List, Pg 235 Original policy
J0801Injection, corticotropin (Acthar Gel), up to 40 unitsNew Hampshire Precertification List, Pg 235 Original policy
J0802Injection, corticotropin (ANI), up to 40 unitsNew Hampshire Precertification List, Pg 236 Original policy
J0870Injection, imetelstat, 1 mgNew Hampshire Precertification List, Pg 236 Original policy
J0881Injection, darbepoetin alfa, 1 mcg (non- ESRD use)New Hampshire Precertification List, Pg 236 Original policy
J0882Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)New Hampshire Precertification List, Pg 236 Original policy
J0885Injection, epoetin alfa, (for non-ESRD use), 1000 unitsNew Hampshire Precertification List, Pg 236 Original policy
J0887Injection, epoetin beta, 1 mcg, (for ESRD on dialysis)New Hampshire Precertification List, Pg 236 Original policy
J0888Injection, epoetin beta, 1 mcg, (for non- ESRD use)New Hampshire Precertification List, Pg 236 Original policy
J0896Injection, luspatercept-aamt, 0.25 mgNew Hampshire Precertification List, Pg 236 Original policy
J0897Injection, denosumab, 1 mgNew Hampshire Precertification List, Pg 236 Original policy
J1072Injection, testosterone cypionate (Azmiro), 1 mgNew Hampshire Precertification List, Pg 236 Original policy
J1073Testosterone pellet, implant, 75 mgNew Hampshire Precertification List, Pg 236 Original policy
J1203Injection, cipaglucosidase alfa-atga, 5 mgNew Hampshire Precertification List, Pg 236 Original policy
J1267Injection, doripenem, 10 mgNew Hampshire Precertification List, Pg 236 Original policy
J1290Injection, ecallantide, 1 mgNew Hampshire Precertification List, Pg 236 Original policy
J1299Injection, eculizumab, 2 mgNew Hampshire Precertification List, Pg 236 Original policy
J1300Injection, eculizumab, 10 mgNew Hampshire Precertification List, Pg 236 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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