Anthem Blue Cross and Blue Shield Virginia prior authorization, page 61

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
Code	Description	Source
J0178	Injection, aflibercept, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0179	Injection, brolucizumab-dbll, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0180	Agalsidase beta injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0202	Injection, alemtuzumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0208	Injection, sodium thiosulfate (Pedmark), 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0217	Injection, velmanase alfa-tycv, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0221	Injection, alglucosidase alfa, (Lumizyme), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0222	Injection, Patisiran, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0223	Injection, givosiran, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0224	Injection, lumasiran, 0.5 m	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0225	Injection, vutrisiran, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0256	Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0257	Injection, alpha 1 proteinase inhibitor (human), (GLASSIA), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0456	Azithromycin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0485	Injection, belatacept, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0490	Injection, belimumab, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0517	Injection, benralizumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0558	Injection, penicillin g benzathine and penicillin g procaine, 100,000 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0561	Injection, penicillin g benzathine, 100,000 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 66 Original policy
J0567	Injection, cerliponase alfa, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0584	Injection, burosumab-twza 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0585	Injection, Onabotulinumtoxina, 1 Unit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0586	Injection, Abobotulinumtoxina, 5 Units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0587	Injection, Rimabotulinumtoxinb, 100 Units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0588	Injection, incobotulinumtoxinA, 1 unit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0589	Injection, daxibotulinumtoxina-lanm, 1 unit	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0593	Injection, 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)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0596	Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0597	Injection, c-1 esterase inhibitor (human), berinert, 10 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0598	Injection, c-1 esterase inhibitor (human), cinryze, 10 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0599	Injection, C-1 esterase inhibitor (human), (Haegarda), 10 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0614	Injection, treosulfan, 50 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0638	Injection, canakinumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0641	Injection, levoleucovorin, not otherwise specified, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0642	Injection, levoleucovorin (khapzory), 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0687	Injection, cefazolin sodium (WG Critical Care), not therapeutically equivalent to J0690, 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0688	Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0689	Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0690	Cefazolin Sodium Injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0696	Ceftriaxone Sodium Injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0698	Cefotaxime Sodium Injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0717	Injection, 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 administer	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0741	Injection, cabotegravir and rilpivirine, 2 mg/3 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0743	Cilastatin Sodium Injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0744	Injection, ciprofloxacin for intravenous infusion, 200 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0775	Injection, collagenase, clostridium histolyticum, 0.01 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0791	Injection, crizanlizumab-tmca, 5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0801	Injection, corticotropin (Acthar Gel), up to 40 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0802	Injection, corticotropin (ANI), up to 40 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0870	Injection, imetelstat, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 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.