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Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 71

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
Q5110Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 mcgNew Hampshire Precertification List, Pg 263 Original policy
Q5111Injection, pegfilgrastim-cbqv (Udenyca), biosimilar, 0.5 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5112Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5113Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5114Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5115Injection, rituximab-abbs, biosimilar, (Truxima), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5116Injection, trastuzumab-qyyp, biosimilar, (Trazimera), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5118Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5119Injection, rituximab-pvvr, biosimilar, (RUXIENCE), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5120Injection, pegfilgrastim-bmez (ZIEXTENZO), biosimilar, 0.5 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5121Injection, infliximab-axxq, biosimilar, (AVSOLA), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5122Injection, pegfilgrastim-apgf (Nyvepria), biosimilar, 0.5 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5123Injection, rituximab-arrx, biosimilar, (Riabni), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5124Injection, ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5125Injection, filgrastim-ayow, biosimilar, (Releuko), 1 mcgNew Hampshire Precertification List, Pg 263 Original policy
Q5126Injection, bevacizumab-maly, biosimilar, (Alymsys), 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5127Injection, pegfilgrastim-fpgk (Stimufend), biosimilar, 0.5 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5128Injection, ranibizumab-eqrn (Cimerli), biosimilar, 0.1 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5129Injection, bevacizumab-adcd (Vegzelma), biosimilar, 10 mgNew Hampshire Precertification List, Pg 263 Original policy
Q5130Injection, pegfilgrastim-pbbk (Fylnetra), biosimilar, 0.5 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5131Injection, adalimumab-aacf (Idacio), biosimilar, 20 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5132Injection, adalimumab-afzb (Abrilada), biosimilar, 10 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5133Injection, tocilizumab-bavi (Tofidence), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5134Injection, natalizumab-sztn (Tyruko), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5135Injection, tocilizumab-aazg (Tyenne), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5136Injection, denosumab-bbdz (Jubbonti/Wyost), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5137Injection, ustekinumab-auub (Wezlana), biosimilar, SC, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5138Injection, ustekinumab-auub (Wezlana), biosimilar, IV, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5140Injection, adalimumab-fkjp, biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5141Injection, adalimumab-aaty, biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5142Injection, adalimumab-ryvk biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5143Injection, adalimumab-adbm, biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5144Injection, adalimumab-aacf (Idacio), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5145Injection, adalimumab-afzb (Abrilada), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5146Injection, trastuzumab-strf (Hercessi), biosimilar, 10 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5147Injection, aflibercept-ayyh (Pavblu), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5149Injection, aflibercept-abzv (Enzeevu), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5150Injection, aflibercept-mrbb (Ahzantive), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q5151Injection, eculizumab-aagh (Epysqli), biosimilarNew Hampshire Precertification List, Pg 264 Original policy
Q5152Injection, eculizumab-aeeb (Bkemv), biosimilarNew Hampshire Precertification List, Pg 264 Original policy
Q5153Injection, aflibercept-yszy (Opuviz), biosimilarNew Hampshire Precertification List, Pg 264 Original policy
Q5160Injection, bevacizumab-nwgd (jobevne), biNew Hampshire Precertification List, Pg 264 Original policy
Q5161Injection, denosumab-kyqq (aukelso/bosaNew Hampshire Precertification List, Pg 264 Original policy
Q5162Injection, denosumab-nxxp (bildyos/bilprevNew Hampshire Precertification List, Pg 264 Original policy
Q9996Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q9997Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q9998Injection, ustekinumab-aekn (selarsdi), 1 mgNew Hampshire Precertification List, Pg 264 Original policy
Q9999Injection, ustekinumab-aauz (Otulfi), biosimilar, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
S0013Esketamine, nasal spray, 1 mgNew Hampshire Precertification List, Pg 264 Original policy
S0189Testosterone pellet. 75 mgNew Hampshire Precertification List, Pg 264 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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