Anthem Blue Cross and Blue Shield Virginia prior authorization, page 67

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
J9275	Injection, cosibelimab-ipdl, 2 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9276	Injection, zanidatamab-hrii, 2 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9277	Injection, pembrolizumab, 1 mg and berahyaluronidase alfa-pmph	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9281	Mitomycin pyelocalyceal instillation, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9282	Mitomycin, intravesical instillation, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9286	Injection, glofitamab-gxbm, 2.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9289	Injection, nivolumab, 2 mg and hyaluronidase-nvhy	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9292	Injection, pemetrexed dipotassium, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9294	Injection, pemetrexed (Hospira), not therapeutically equivalent to J9305, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9296	Injection, pemetrexed (Accord), not therapeutically equivalent to J9305, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9297	Injection, pemetrexed (sandoz), not therapeutically equivalent to j9305, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9298	Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9299	Injection, nivolumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9301	Injection, obinutuzumab, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9302	Injection, ofatumumab, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9303	Injection, panitumumab, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9304	Injection, pemetrexed (pemfexy), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9305	Injection, pemetrexed, NOS,10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9306	Injection, pertuzumab, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9308	Injection, ramucirumab, 5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9309	Injection, polatuzumab vedotin-piiq, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9312	Injection, rituximab, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9314	Injection, pemetrexed (Teva), not therapeutically equivalent to J9305, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9316	Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9317	Injection, sacituzumab govitecan-hziy, 2.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9318	Injection, romidepsin, nonlyophilized, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9319	Injection, romidepsin, lyophilized, 0.1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9321	Injection, epcoritamab-bysp, 0.16 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9322	Injection, pemetrexed (BluePoint), not therapeutically equivalent to J9305, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9323	Injection, pemetrexed (hospira) not therapeutically equivalent to j9305, 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9324	Injection, pemetrexed (pemrydi rtu), 10 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9325	Injection, talimogene laherparepvec, per 1 million plaque forming units	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9326	Injection, telisotuzumab vedotin-tllv, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9329	Injection, tislelizumab-jsgr, 1mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9331	Injection, sirolimus protein-bound particles, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9332	Injection, efgartigimod alfa-fcab, 2mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9333	Injection, rozanolixizumab-noli, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9334	Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9345	Injection, retifanlimab-dlwr, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9347	Injection, tremelimumab-actl, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9348	Injection, naxitamab-gqgk, 1 m	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9349	Injection, tafasitamab-cxix, 2 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9350	Injection, mosunetuzumab-axgb, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9353	Injection, margetuximab-cmkb, 5 m	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9354	Injection, ado-trastuzumab emtansine, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9358	Injection, fam-trastuzumab deruxtecan-nxki, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9359	Injection, loncastuximab tesirine-lpyl, 0.075 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9361	Injection, efbemalenograstim alfa-vuxw, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9376	Injection, pozelimab-bbfg, 1 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy
J9380	Injection, teclistamab-cqyv, 0.5 mg	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 72 Original policy

Sources

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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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