Anthem Blue Cross and Blue Shield Virginia prior authorization, page 63

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
J1561	Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1566	Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1568	Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g.	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1569	Injection, immune globulin, (gammagard liquid/gammagard liquid erc), 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1572	Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1575	Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1576	Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1577	Injection, immune globulin (qivigy), 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1595	Injection, glatiramer acetate, 20 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1599	Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1602	Injection, golimumab, 1 mg, for intravenous use	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1628	Injection, guselkumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1632	Injection, brexanolone, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1743	Injection, idursulfase, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1744	Injection, icatibant, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1745	Injection, infliximab, excludes biosimilar, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1746	Injection, ibalizumab-uiyk, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1748	Injection, infliximab-dyyb (Zymfentra), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1786	Injection, imiglucerase, 10 units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1823	Injection, inebilizumab-cdon, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1826	Injection, interferon beta-1a, 30 mcg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1830	Interferon Beta-1b / .25 Mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1930	Injection, lanreotide, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1931	Laronidase injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1932	Injection, lanreotide, (cipla), 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1951	Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 m	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1954	Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1956	Levofloxacin Injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J1961	Injection, lenacapavir (only for use as HIV treatment), 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 68 Original policy
J2170	INJECTION, MECASERMIN, 1 MG	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2182	Injection, mepolizumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2183	Injection, meropenem (WG Critical Care), not therapeutically equivalent to J2185, 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2184	Injection, meropenem (B. Braun), not therapeutically equivalent to J2185, 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2185	Injection, meropenem, 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2267	Injection, mirikizumab-mrkz, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2277	Injection, motixafortide, 0.25 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2278	Injection, ziconotide, 1 mcg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2280	Injection, moxifloxacin, 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2281	Injection, moxifloxacin (Fresenius Kabi), not therapeutically equivalent to J2280, 100 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2323	Imjection, natalizumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2326	Injection, nusinersen, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2327	Injection, risankizumab-rzaa, intravenous, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2329	Injection, ublituximab-xiiy, 1mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2350	Injection, ocrelizumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2353	Injection, octreotide, depot form for intramuscular injection, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2354	Injection, octreotide, non-depot form for subcutaneous or intravenous	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2356	Injection, tezepelumab-ekko, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2357	Omalizumab injection	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2502	Injection, pasireotide long acting, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy
J2506	Injection, pegfilgrastim, excludes biosimilar, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 69 Original policy

Sources

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