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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 59

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
J2540Injection, penicillin G potassium, up to 600,000 unitsNew Hampshire Precertification List, Pg 239 Original policy
J2562Injection, plerixafor, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2777Injection, faricimab-svoa, 0.1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2778Injection, ranibizumab, 0.1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2779Injection, ranibizumab, via intravitreal implant (Susvimo), 0.1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2781Injection, pegcetacoplan, intravitreal, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2782Injection, avacincaptad pegol, 0.1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2786Injection, reslizumab, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2787Riboflavin 5'-phosphate, ophthalmic solution, up to 3 mlNew Hampshire Precertification List, Pg 239 Original policy
J2793Injection, rilonacept, 1 mgNew Hampshire Precertification List, Pg 239 Original policy
J2796Injection, romiplostim, 10 mcgNew Hampshire Precertification List, Pg 239 Original policy
J2802Injection, romiplostim, 1 mcgNew Hampshire Precertification List, Pg 239 Original policy
J2820Injection, sargramostim (GM-CSF), 50 mcgNew Hampshire Precertification List, Pg 239 Original policy
J2840Injection, sebelipase alfa, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J2860Injection, siltuximab, 10 mgNew Hampshire Precertification List, Pg 240 Original policy
J2916Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mgNew Hampshire Precertification List, Pg 240 Original policy
J2940Injection, somatrem, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J2941Injection, somatropin, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J2998Injection, plasminogen, human-tvmh, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3032Injection, eptinezumab-jjmr, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3055Injection, talquetamab-tgvs, 0.25 mgNew Hampshire Precertification List, Pg 240 Original policy
J3060Injection, taliglucerace alfa, 10 unitsNew Hampshire Precertification List, Pg 240 Original policy
J3111Injection, romosozumab-aqqg, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3241Injection, teprotumumab-trbw, 10 mgNew Hampshire Precertification List, Pg 240 Original policy
J3245Injection, tildrakizumab, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3247Injection, secukinumab, IV, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3262Injection, tocilizumab, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3263Injection, toripalimab-tpzi, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3285Injection, treprostinil, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3299Injection, triamcinolone acetonide (Xipere), 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3304Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3315Injection, triptorelin pamoate, 3.75 mgNew Hampshire Precertification List, Pg 240 Original policy
J3316Injection, triptorelin, extended-release, 3.75 mgNew Hampshire Precertification List, Pg 240 Original policy
J3357Ustekinumab, for subcutaneous injection, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3358Ustekinumab, for intravenous injection, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3380Injection, vedolizumab, IV, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3385Injection, velaglucerase alfa, 100 unitsNew Hampshire Precertification List, Pg 240 Original policy
J3392Injection, exagamglogene autotemcel, per treatmentNew Hampshire Precertification List, Pg 240 Original policy
J3393Injection, betibeglogene autotemcel, per treatmentNew Hampshire Precertification List, Pg 240 Original policy
J3394Injection, lovotibeglogene autotemcel, per treatmentNew Hampshire Precertification List, Pg 240 Original policy
J3397Injection, vestronidase alfa-vjbk, 1 mgNew Hampshire Precertification List, Pg 240 Original policy
J3398Injection, voretigene neparvovec-rzyl, 1 billion vector genomesNew Hampshire Precertification List, Pg 240 Original policy
J3399Injection, onasemnogene abeparvovec- xioi, per treatment, up to 5x10New Hampshire Precertification List, Pg 240 Original policy
J3401Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 109 PFU/ml vector genomes, per 0.1 mlNew Hampshire Precertification List, Pg 240 Original policy
J3402Injection, remestemcel-l-rknd, per therapeutic doseNew Hampshire Precertification List, Pg 240 Original policy
J3403Revakinagene taroretcel-lwey, per implantNew Hampshire Precertification List, Pg 240 Original policy
J3489Injection, zoledronic acid, 1 mgNew Hampshire Precertification List, Pg 241 Original policy
J3490Unclassified drugsNew Hampshire Precertification List, Pg 241 Original policy
J3590Unclassified biologicsNew Hampshire Precertification List, Pg 241 Original policy
J7170Injection, emicizumab-kxwh, 0.5 mgNew Hampshire Precertification List, Pg 241 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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