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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 57

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
J1301Injection, edaravone, 1 mgNew Hampshire Precertification List, Pg 236 Original policy
J1302Injection, sutimlimab-jome, 10 mgNew Hampshire Precertification List, Pg 236 Original policy
J1303Injection, ravulizumab-cwvz, 10 mgNew Hampshire Precertification List, Pg 236 Original policy
J1304Injection, tofersen, 1 mgNew Hampshire Precertification List, Pg 236 Original policy
J1305Injection, evinacumab-dgnb, 5 mgNew Hampshire Precertification List, Pg 236 Original policy
J1306Injection, inclisiran, 1 mgNew Hampshire Precertification List, Pg 236 Original policy
J1307Injection, crovalimab-akkz, 10 mgNew Hampshire Precertification List, Pg 236 Original policy
J1322Injection, elosulfase alfa, 1mgNew Hampshire Precertification List, Pg 236 Original policy
J1323Injection, elranatamab-bcmm, 1 mgNew Hampshire Precertification List, Pg 236 Original policy
J1325Injection, epoprostenol, 0.5 mgNew Hampshire Precertification List, Pg 236 Original policy
J1326Injection, zolbetuximab-clzb, 2 mgNew Hampshire Precertification List, Pg 236 Original policy
J1335Injection, ertapenem sodium, 500 mgNew Hampshire Precertification List, Pg 236 Original policy
J1411Injection, etranacogene dezaparvovec- drlb, per therapeutic doseNew Hampshire Precertification List, Pg 236 Original policy
J1412Injection, valoctocogene roxaparvovec- rvox, per ml, containing nominal 2 x 1013 vector genomesNew Hampshire Precertification List, Pg 236 Original policy
J1413Injection, delandistrogene moxeparvovec- rokl, per therapeutic doseNew Hampshire Precertification List, Pg 236 Original policy
J1414Injection, fidanacogene elaparvovec-dzkt, per therapeutic doseNew Hampshire Precertification List, Pg 236 Original policy
J1426Injection, casimersen, 10 mgNew Hampshire Precertification List, Pg 236 Original policy
J1427Injection, viltolarsen, 10 mgNew Hampshire Precertification List, Pg 236 Original policy
J1428Injection, eteplirsen, 10 mgNew Hampshire Precertification List, Pg 236 Original policy
J1429Injection, golodirsen, 10 mgNew Hampshire Precertification List, Pg 236 Original policy
J1437Injection, ferric derisomaltose, 10 mgNew Hampshire Precertification List, Pg 236 Original policy
J1438Injection, etanercept, 25 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 237 Original policy
J1439Injection, ferric carboxymaltose, 1mgNew Hampshire Precertification List, Pg 237 Original policy
J1440Fecal microbiota, live - jslm, 1 mlNew Hampshire Precertification List, Pg 237 Original policy
J1442Injection, filgrastim (G-CSF), excludes biosimilars, 1 mcgNew Hampshire Precertification List, Pg 237 Original policy
J1447Injection, tbo-filgrastim, 1 microgramNew Hampshire Precertification List, Pg 237 Original policy
J1448Injection, trilaciclib, 1 mgNew Hampshire Precertification List, Pg 237 Original policy
J1449Injection, eflapegrastim-xnst, 0.1 mgNew Hampshire Precertification List, Pg 237 Original policy
J1450Injection, fluconazole, 200 mgNew Hampshire Precertification List, Pg 237 Original policy
J1454Injection, fosnetupitant 235 mg and palonosetron 0.25 mgNew Hampshire Precertification List, Pg 237 Original policy
J1458Injection, galsulfase, 1 mgNew Hampshire Precertification List, Pg 237 Original policy
J1459Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mgNew Hampshire Precertification List, Pg 237 Original policy
J1460Injection, gamma globulin, intramuscular, 1 ccNew Hampshire Precertification List, Pg 237 Original policy
J1551Injection, immune globulin (cutaquig), 100 mgNew Hampshire Precertification List, Pg 237 Original policy
J1552Injection, immune globulin (Alyglo), 500 mgNew Hampshire Precertification List, Pg 237 Original policy
J1554Injection, immune globulin (asceniv), 500 mgNew Hampshire Precertification List, Pg 237 Original policy
J1555Injection, immune globulin (Cuvitru), 100 mgNew Hampshire Precertification List, Pg 237 Original policy
J1556Injection, immune globulin (bivigam), 500 mgNew Hampshire Precertification List, Pg 237 Original policy
J1557Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mgNew Hampshire Precertification List, Pg 237 Original policy
J1558Injection, immune globulin (xembify), 100 mgNew Hampshire Precertification List, Pg 237 Original policy
J1559Injection, immune globulin (hizentra), 100 mgNew Hampshire Precertification List, Pg 237 Original policy
J1560Injection, gamma globulin, intramuscular, over 10 ccNew Hampshire Precertification List, Pg 237 Original policy
J1561Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mgNew Hampshire Precertification List, Pg 237 Original policy
J1566Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mgNew Hampshire Precertification List, Pg 237 Original policy
J1568Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g.New Hampshire Precertification List, Pg 237 Original policy
J1569Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mgNew Hampshire Precertification List, Pg 237 Original policy
J1572Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mgNew Hampshire Precertification List, Pg 238 Original policy
J1575Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulinNew Hampshire Precertification List, Pg 238 Original policy
J1576Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mgNew Hampshire Precertification List, Pg 238 Original policy
J1595Injection, glatiramer acetate, 20 mgNew Hampshire Precertification List, Pg 238 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.

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