Anthem Blue Cross and Blue Shield Virginia prior authorization, page 62

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
J0881	Injection, darbepoetin alfa, 1 mcg (non-ESRD use)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0882	Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0885	Injection, epoetin alfa, (for non-ESRD use), 1000 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0887	Injection, epoetin beta, 1 microgram, (for esrd on dialysis)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0888	Injectin, epoetin beta, 1 microgram, (for non esrd use)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0896	Injection, luspatercept-aamt, 0.25 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J0897	Injection, denosumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1203	Injection, cipaglucosidase alfa-atga, 5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1290	Injection, ecallantide, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1301	Injection, edaravone, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1302	Injection, sutimlimab-jome, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1303	Injection, ravulizumab-cwvz, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1304	Injection, tofersen, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1305	Injection, evinacumab-dgnb, 5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1306	Injection, inclisiran, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1322	Injection, elosulfase alfa, 1mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1323	Injection, elranatamab-bcmm, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1325	Epoprostenol Injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1326	Injection, zolbetuximab-clzb, 2 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1335	Injection, ertapenem sodium, 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1411	Injection, etranacogene dezaparvovec-drlb, per therapeutic dose	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1412	Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1413	Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1414	Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 67 Original policy
J1426	Injection, casimersen, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1427	Injection, viltolarsen, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1428	Injection, eteplirsen, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1429	Injection, golodirsen, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1437	Injection, ferric derisomaltose, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1438	Etanercept Injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1439	Injection, ferric carboxymaltose, 1mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1440	Fecal microbiota, live - jslm, 1 ml	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1442	5G-CSFexcludes biosimilars, 1 microgram	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1447	Injection, tbo-filgrastim, 1 microgram	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1448	Injection, trilaciclib, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1449	Injection, eflapegrastim-xnst, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1450	Fluconazole	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1454	Injection, fosnetupitant 235 mg and palonosetron 0.25 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1458	INJECTION, GALSULFASE, 1 MG	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1459	Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1460	Gamma Globulin 1 Cc Inj	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1551	Injection, immune globulin (cutaquig), 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1552	Injection, immune globulin (alyglo), 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1554	Injection, immune globulin (asceniv), 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1555	Injection, immune globulin (Cuvitru), 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1556	Injection, immune globulin (bivigam), 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1557	Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1558	Injection, immune globulin (xembify), 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1559	Injection, immune globulin (hizentra), 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1560	Gamma Globulin > 10 Cc Inj	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy

Sources

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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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