Anthem Blue Cross Blue Shield of California policy
Anthem Medical Specialty Pharmacy (MSP) CVS Drug List 10/01/2021
Anthem Medical Specialty Pharmacy (MSP) CVS Drug List 10/01/2021 is a public Anthem Blue Cross Blue Shield of California policy. It lists 102 CPT or HCPCS codes, 94 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| J0129 | On the list | Abatacept (Orencia) | Policies naming J0129 |
| J0180 | On the list | Agalsidase Beta (Fabrazyme) | Policies naming J0180 |
| J0202 | On the list | Alemtuzumab (Lemtrada) | Policies naming J0202 |
| J0221 | On the list | Alglucosidase alfa (Lumizyme) | Policies naming J0221 |
| J0256 | On the list | Alpha 1 proteinase inhibitor (Aralast) | Policies naming J0256 |
| J0257 | On the list | Alpha 1 proteinase inhibitor (Glassia) | Policies naming J0257 |
| J0485 | On the list | Belatacept (Nulojix) | Policies naming J0485 |
| J0490 | On the list | Belimumab (Benlysta IV) | Policies naming J0490 |
| J0517 | On the list | Benralizumab (Fasenra) | Policies naming J0517 |
| J0586 | On the list | AbobotulinumtoxinA (Dysport) | Policies naming J0586 |
| J0587 | On the list | RimabotulinumtoxinB (Myobloc) | Policies naming J0587 |
| J0593 | On the list | Lanadelumab-flyo (Takhzyro) | Policies naming J0593 |
| J0596 | On the list | Recombinant C1 esterase inhibitor (Ruconest) | Policies naming J0596 |
| J0597 | On the list | C1 esterase inhibitor (human) (Berinert) | Policies naming J0597 |
| J0598 | On the list | C1 esterase inhibitor (human) (Cinryze) | Policies naming J0598 |
| J0599 | On the list | C1 esterase inhibitor (human) (Haegarda) | Policies naming J0599 |
| J0638 | On the list | Canakinumab (Ilaris) | Policies naming J0638 |
| J0881 | On the list | Darbepoetin Alfa (Aranesp) | Policies naming J0881 |
| J0882 | On the list | Darbepoetin Alfa (Aranesp) | Policies naming J0882 |
| J0887 | On the list | Epoetin beta (Mircera) | Policies naming J0887 |
| J0888 | On the list | Epoetin beta (Mircera) | Policies naming J0888 |
| J0897 | On the list | Denosumab (Prolia, Xgeva) | Policies naming J0897 |
| J1290 | On the list | Ecallantide (Kalbitor) | Policies naming J1290 |
| J1300 | Not listed | Policies naming J1300 | |
| J1303 | On the list | Ravulizumab-cwvz (Ultomiris) | Policies naming J1303 |
| J1325 | On the list | Epoprostenol (Flolan) | Policies naming J1325 |
| J1459 | On the list | Immune globulin, IV, non-lyophilized (Privigen) | Policies naming J1459 |
| J1460 | On the list | Gamma globulin, IM (Gamastan S/D) | Policies naming J1460 |
| J1555 | On the list | Immune Globulin (Cuvitru) | Policies naming J1555 |
| J1557 | On the list | Immune Globulin (Gammaplex) | Policies naming J1557 |
| J1558 | On the list | Immune Globulin (Human)-klhw (Xembify) | Policies naming J1558 |
| J1559 | On the list | Immune Globulin (Human) Subcutaneous (Hizentra) | Policies naming J1559 |
| J1561 | On the list | Immune Globulin (Human) IV or Subcutaneous (Gamunex- C/Gammaked) | Policies naming J1561 |
| J1566 | On the list | Immune Globulin (Human) IV (Gammagard SD) | Policies naming J1566 |
| J1568 | On the list | Immune Globulin (Human) IV (Octagam) | Policies naming J1568 |
| J1569 | On the list | Immune Globulin (Gammagard Liquid, Gammagard Liquid ERC) | Policies naming J1569 |
| J1572 | On the list | Immune Globulin (Human) IV (Flebogamma) | Policies naming J1572 |
| J1575 | On the list | Immune Globulin (Human) IV (HyQvia) | Policies naming J1575 |
| J1599 | Not listed | Policies naming J1599 | |
| J1743 | On the list | Idursulfase (Elaprase) | Policies naming J1743 |
| J1950 | On the list | Leuprolide acetate (for depot suspension) (Lupron Depot-Ped) | Policies naming J1950 |
| J2182 | On the list | Mepolizumab (Nucala) | Policies naming J2182 |
| J2323 | On the list | Natalizumab (Tysabri) | Policies naming J2323 |
| J2350 | On the list | Ocrelizumab (Ocrevus) | Policies naming J2350 |
| J2357 | On the list | Omalizumab (Xolair) | Policies naming J2357 |
| J2507 | On the list | Pegloticase (Krystexxa) | Policies naming J2507 |
| J2786 | On the list | Reslizumab (Cinqair) | Policies naming J2786 |
| J2796 | Not listed | Policies naming J2796 | |
| J3111 | On the list | Romosozumab-aqqg (Evenity) | Policies naming J3111 |
| J3262 | On the list | Tocilizumab (Actemra) | Policies naming J3262 |
| J3315 | On the list | Triptorelin pamoate (Trelstar, Trelstar Depot, Trelstar LA) | Policies naming J3315 |
| J3380 | On the list | Vedolizumab (Entyvio) | Policies naming J3380 |
| J3385 | On the list | Velaglucerase alfa (VPRIV) | Policies naming J3385 |
| J7170 | On the list | Emicizumab-kxwh (Hemlibra) | Policies naming J7170 |
| J7183 | On the list | Antihemophilic factor VIII (Wilate) | Policies naming J7183 |
| J7185 | On the list | Factor VIII (antihemophilic factor, recombinant) (Xyntha, Xyntha Solofuse) | Policies naming J7185 |
| J7186 | On the list | Antihemophilic factor VIII (Alphanate) | Policies naming J7186 |
| J7187 | On the list | Antihemophilic factor VIII (Humate-P) | Policies naming J7187 |
| J7189 | On the list | Factor VIIa Recombinant (Novoseven RT) | Policies naming J7189 |
| J7192 | On the list | Factor VIII (antihemophilic factor, recombinant) (Advate, Kogenate-FS) | Policies naming J7192 |
| J7195 | On the list | Factor IX Recombinant (Benefix) | Policies naming J7195 |
| J7201 | On the list | Factor IX, Fc fusion protein (recombinant) (Alprolix) | Policies naming J7201 |
| J7205 | On the list | Factor VIII Fc fusion protein, (recombinant) (Eloctate) | Policies naming J7205 |
| J7207 | On the list | Factor VIII, (anti-hemophilic factor, recombinant), pegylated (Adynovate) | Policies naming J7207 |
| J7209 | On the list | Factor VIII, (antihemophilic factor, recombinant) (Nuwiq) | Policies naming J7209 |
| J7210 | On the list | Factor VIII, (Antihemophilic Factor, recombinant) (Afstyla) | Policies naming J7210 |
| J7211 | On the list | Factor VIII, (antihemophilic factor, recombinant( (Kovaltry) | Policies naming J7211 |
| J9022 | On the list | Atezolizumab (Tecentriq) | Policies naming J9022 |
| J9023 | On the list | Avelumab (Bavencio) | Policies naming J9023 |
| J9039 | On the list | Blinatumomab (Blincyto) | Policies naming J9039 |
| J9042 | On the list | Brentuximab vedotin (Adcetris) | Policies naming J9042 |
| J9055 | On the list | Cetuximab (Erbitux) | Policies naming J9055 |
| J9145 | On the list | Daratumumab (Darzalex) | Policies naming J9145 |
| J9173 | On the list | Durvalumab (Imfinzi) | Policies naming J9173 |
| J9176 | On the list | Elotuzumab (Empliciti) | Policies naming J9176 |
| J9202 | On the list | Goserelin acetate (Zoladex) | Policies naming J9202 |
| J9217 | On the list | Leuprolide acetate (for depot suspension) (Lupron Depot) | Policies naming J9217 |
| J9225 | Not listed | Policies naming J9225 | |
| J9226 | On the list | Histrelin acetate (Supprelin LA) | Policies naming J9226 |
| J9228 | On the list | Ipilimumab (Yervoy) | Policies naming J9228 |
| J9266 | On the list | Asparaginase (Oncaspar) | Policies naming J9266 |
| J9271 | On the list | Pembrolizumab (Keytruda) | Policies naming J9271 |
| J9299 | On the list | Nivolumab (Opdivo) | Policies naming J9299 |
| J9301 | On the list | Obinutuzumab (Gazyva) | Policies naming J9301 |
| J9303 | On the list | Panitumumab (Vectibix) | Policies naming J9303 |
| J9306 | On the list | Pertuzumab (Perjeta) | Policies naming J9306 |
| J9308 | On the list | Ramucirumab (Cyramza) | Policies naming J9308 |
| J9311 | Not listed | Policies naming J9311 | |
| J9312 | On the list | Rituximab (Rituxan) | Policies naming J9312 |
| J9354 | On the list | Ado-trastuzumab emtansine (Kadcyla) | Policies naming J9354 |
| J9355 | Not listed | Policies naming J9355 | |
| J9395 | Not listed | Policies naming J9395 | |
| Q5104 | On the list | Infliximab-abda (Renflexis) | Policies naming Q5104 |
| Q5106 | On the list | Epoetin alfa-epbx (Retacrit) | Policies naming Q5106 |
| Q5112 | On the list | Ontruzant (trastuzumab-dttb) | Policies naming Q5112 |
| Q5113 | On the list | Herzuma (trastuzumab-pkrb) | Policies naming Q5113 |
| Q5114 | On the list | Ogivri (trastuzumab-dkst) | Policies naming Q5114 |
| Q5115 | On the list | Tituximab-abbs (Truxima) | Policies naming Q5115 |
| Q5116 | On the list | Trazimera (trastuzumab-qyyp) | Policies naming Q5116 |
| Q5117 | Not listed | Policies naming Q5117 | |
| Q5119 | On the list | Rituximab-pvvr (Ruxience) | Policies naming Q5119 |
| Q5123 | On the list | Rituximab-arrx (RIABNI) | Policies naming Q5123 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list