Anthem Blue Cross Blue Shield of California policy
Medicare Advantage Precertification Requirements – 2019
Medicare Advantage Precertification Requirements – 2019 is a public Anthem Blue Cross Blue Shield of California policy. It lists 191 CPT or HCPCS codes, 135 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
- States
- CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, VA, WI
- Source
- www.anthem.com
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 |
|---|---|---|---|
| 79403 | On the list | Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion [when specified as injection of yttrium Y-90 ibritumomab tiuxetan (Zevalin)] | Policies naming 79403 |
| A9543 | On the list | Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40mCi (Zevalin) | Policies naming A9543 |
| A9606 | On the list | Radium ra-223 dichloride, therapeutic (Xofigo) | Policies naming A9606 |
| A9699 | Not listed | Policies naming A9699 | |
| C9014 | Not listed | Policies naming C9014 | |
| C9016 | Not listed | Policies naming C9016 | |
| C9024 | Not listed | Policies naming C9024 | |
| C9028 | Not listed | Policies naming C9028 | |
| C9029 | Not listed | Policies naming C9029 | |
| C9030 | Not listed | Policies naming C9030 | |
| C9031 | Not listed | Policies naming C9031 | |
| C9032 | Not listed | Policies naming C9032 | |
| C9257 | On the list | Bevacizumab, 0.25 mg intravitreal (Avastin) | Policies naming C9257 |
| C9399 | On the list | Unclassified drugs or biologicals [when specified as lifileucel (Amtagvi)] or [when specified as eladocagene exuparvovec- tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] or [when describing a product with no specific code indicated as investigational and not medically necessary] | Policies naming C9399 |
| C9463 | Not listed | Policies naming C9463 | |
| C9464 | Not listed | Policies naming C9464 | |
| C9465 | Not listed | Policies naming C9465 | |
| C9466 | Not listed | Policies naming C9466 | |
| C9467 | Not listed | Policies naming C9467 | |
| C9468 | Not listed | Policies naming C9468 | |
| C9492 | Not listed | Policies naming C9492 | |
| J0129 | On the list | Abatacept (Orencia) | Policies naming J0129 |
| J0135 | Not listed | Policies naming J0135 | |
| J0178 | On the list | Aflibercept (Eylea) | Policies naming J0178 |
| J0202 | On the list | Alemtuzumab (Lemtrada) | Policies naming J0202 |
| J0485 | On the list | Belatacept (Nulojix) | Policies naming J0485 |
| J0490 | On the list | Belimumab (Benlysta IV) | Policies naming J0490 |
| J0585 | On the list | OnabotulinumtoxinA (Botox) | Policies naming J0585 |
| J0586 | On the list | AbobotulinumtoxinA (Dysport) | Policies naming J0586 |
| J0587 | On the list | RimabotulinumtoxinB (Myobloc) | Policies naming J0587 |
| J0588 | On the list | IncobotulinumtoxinA (Xeomin) | Policies naming J0588 |
| J0596 | On the list | Recombinant C1 esterase inhibitor (Ruconest) | Policies naming J0596 |
| J0881 | On the list | Darbepoetin Alfa (Aranesp) | Policies naming J0881 |
| J0885 | On the list | Injection, epoetin alfa (for non-ESRD use), 1000 units (Epogen, Procrit) | Policies naming J0885 |
| J0888 | On the list | Epoetin beta (Mircera) | Policies naming J0888 |
| J0897 | On the list | Denosumab (Prolia, Xgeva) | Policies naming J0897 |
| J1300 | Not listed | Policies naming J1300 | |
| J1325 | On the list | Epoprostenol (Flolan) | Policies naming J1325 |
| J1428 | On the list | Eteplirsen (Exondys 51) | Policies naming J1428 |
| J1438 | On the list | Etanercept (Enbrel) | Policies naming J1438 |
| J1442 | On the list | Filgrastim (Neupogen) | Policies naming J1442 |
| J1447 | On the list | Tbo-Filgrastim (Granix) | Policies naming J1447 |
| J1453 | Not listed | Policies naming J1453 | |
| J1459 | On the list | Immune globulin, IV, non-lyophilized (Privigen) | Policies naming J1459 |
| J1555 | On the list | Immune Globulin (Cuvitru) | Policies naming J1555 |
| J1556 | On the list | Immune Globulin (Bivigam) | Policies naming J1556 |
| J1557 | On the list | Immune Globulin (Gammaplex) | Policies naming J1557 |
| 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 |
| J1562 | Not listed | Policies naming J1562 | |
| 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 | |
| J1602 | On the list | Golimumab (Simponi Aria) | Policies naming J1602 |
| J1627 | Not listed | Policies naming J1627 | |
| J1740 | Not listed | Policies naming J1740 | |
| J1745 | On the list | Infliximab (Remicade) | Policies naming J1745 |
| J1950 | On the list | Leuprolide acetate (for depot suspension) (Lupron Depot-Ped) | Policies naming J1950 |
| J2182 | On the list | Mepolizumab (Nucala) | Policies naming J2182 |
| J2278 | On the list | Ziconotide Intrathecal Infusion (Prialt) | Policies naming J2278 |
| J2323 | On the list | Natalizumab (Tysabri) | Policies naming J2323 |
| J2326 | On the list | Nusinersen (Spinraza) | Policies naming J2326 |
| J2350 | On the list | Ocrelizumab (Ocrevus) | Policies naming J2350 |
| J2353 | On the list | Octreotide, depot form (Sandostatin LAR depot) | Policies naming J2353 |
| J2354 | On the list | Octreotide (Sandostatin) | Policies naming J2354 |
| J2355 | Not listed | Policies naming J2355 | |
| J2357 | On the list | Omalizumab (Xolair) | Policies naming J2357 |
| J2469 | Not listed | Policies naming J2469 | |
| J2503 | Not listed | Policies naming J2503 | |
| J2505 | Not listed | Policies naming J2505 | |
| J2507 | On the list | Pegloticase (Krystexxa) | Policies naming J2507 |
| J2778 | On the list | Ranibizumab (Lucentis) | Policies naming J2778 |
| J2786 | On the list | Reslizumab (Cinqair) | Policies naming J2786 |
| J2796 | Not listed | Policies naming J2796 | |
| J2820 | On the list | Sargramostim (Leukine) | Policies naming J2820 |
| J2860 | Not listed | Policies naming J2860 | |
| J2941 | On the list | Somatropin (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton) | Policies naming J2941 |
| J3262 | On the list | Tocilizumab (Actemra) | Policies naming J3262 |
| J3285 | On the list | Treprostinil (Remodulin) | Policies naming J3285 |
| J3315 | On the list | Triptorelin pamoate (Trelstar, Trelstar Depot, Trelstar LA) | Policies naming J3315 |
| J3358 | On the list | Ustekinumab (Stelara) | Policies naming J3358 |
| J3380 | On the list | Vedolizumab (Entyvio) | Policies naming J3380 |
| J3489 | On the list | Injection, zoledronic acid, 1 mg (Reclast) | Policies naming J3489 |
| J3490 | On the list | Unclassified drugs or biologicals [when specified as eladocagene exuparvovec-tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as elivaldogene autotemcel (Skysona)] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] | Policies naming J3490 |
| J3590 | On the list | Unclassified drugs or biologicals [when specified as eladocagene exuparvovec-tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as allogeneic processed thymus tissue-agdc (RETHYMIC) implant] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] | Policies naming J3590 |
| J7175 | On the list | Factor X (Coagadex) | Policies naming J7175 |
| J7178 | On the list | Fibrinogen concentrate )RiaSTAP) | Policies naming J7178 |
| J7179 | On the list | Von Willebrand Factor (Vonvendi) | Policies naming J7179 |
| J7180 | On the list | Factor XIII concentrate (human) (Corifact) | Policies naming J7180 |
| J7181 | On the list | Coagulation factor XIII A-subunit (recombinant) (Tretten) | Policies naming J7181 |
| J7182 | On the list | Factor VIII (antihemophilic factor, recombinant) (Novoeight) | Policies naming J7182 |
| 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 |
| J7188 | On the list | Antihemophilic Factor VIII (Obizur) | Policies naming J7188 |
| J7189 | On the list | Factor VIIa Recombinant (Novoseven RT) | Policies naming J7189 |
| J7190 | On the list | (Factor VIII) human plasma-derived (Hemofil M) | Policies naming J7190 |
| J7191 | On the list | Antihemophilic Factor VIII (Obizur) | Policies naming J7191 |
| J7192 | On the list | Factor VIII (antihemophilic factor, recombinant) (Advate, Kogenate-FS) | Policies naming J7192 |
| J7193 | On the list | Coagulation factor IX (human) (AlphaNine SD) | Policies naming J7193 |
| J7194 | On the list | Factor IX Complex Human (Profilnine SD) | Policies naming J7194 |
| J7195 | On the list | Factor IX Recombinant (Benefix) | Policies naming J7195 |
| J7198 | On the list | Anti-inhibitor coagulant complex (FEIBA) | Policies naming J7198 |
| J7199 | Not listed | Policies naming J7199 | |
| J7200 | On the list | Factor IX Recombinant (Rixubis) | Policies naming J7200 |
| J7201 | On the list | Factor IX, Fc fusion protein (recombinant) (Alprolix) | Policies naming J7201 |
| J7202 | On the list | Factor IX, albumin fusion protein, (recombinant) (Idelvion) | Policies naming J7202 |
| 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 |
| J7311 | On the list | Fluocinolone acetonide, intravitreal implant (Retisert) | Policies naming J7311 |
| J7312 | On the list | Dexamethasone intravitreal implant (Ozurdex) | Policies naming J7312 |
| J7313 | On the list | Fluocinolone acetonide intravitreal implant (Iluvien) | Policies naming J7313 |
| J7316 | Not listed | Policies naming J7316 | |
| J7320 | Not listed | Policies naming J7320 | |
| J7321 | Not listed | Policies naming J7321 | |
| J7322 | Not listed | Policies naming J7322 | |
| J7323 | Not listed | Policies naming J7323 | |
| J7324 | Not listed | Policies naming J7324 | |
| J7325 | Not listed | Policies naming J7325 | |
| J7326 | Not listed | Policies naming J7326 | |
| J7327 | Not listed | Policies naming J7327 | |
| J7328 | Not listed | Policies naming J7328 | |
| J7340 | On the list | Carbidopa/levodopa enteral suspension (Duopa) | Policies naming J7340 |
| J7686 | On the list | Treprostinil (Tyvaso) | Policies naming J7686 |
| J9010 | Not listed | Policies naming J9010 | |
| J9015 | On the list | Aldesleukin (Proleukin) | Policies naming J9015 |
| J9022 | On the list | Atezolizumab (Tecentriq) | Policies naming J9022 |
| J9023 | On the list | Avelumab (Bavencio) | Policies naming J9023 |
| J9025 | Not listed | Policies naming J9025 | |
| J9034 | On the list | Bendamustine (Bendeka) | Policies naming J9034 |
| J9035 | On the list | Avastin (bevacizumab) | Policies naming J9035 |
| J9039 | On the list | Blinatumomab (Blincyto) | Policies naming J9039 |
| J9042 | On the list | Brentuximab vedotin (Adcetris) | Policies naming J9042 |
| J9043 | On the list | Cabazitaxel (Jevtana) | Policies naming J9043 |
| J9047 | On the list | Carfilzomib (Kyprolis) | Policies naming J9047 |
| J9055 | On the list | Cetuximab (Erbitux) | Policies naming J9055 |
| J9145 | On the list | Daratumumab (Darzalex) | Policies naming J9145 |
| J9155 | Not listed | Policies naming J9155 | |
| J9176 | On the list | Elotuzumab (Empliciti) | Policies naming J9176 |
| J9179 | On the list | Eribulin mesylate (Halaven) | Policies naming J9179 |
| J9202 | On the list | Goserelin acetate (Zoladex) | Policies naming J9202 |
| J9203 | On the list | Gemtuzumab ozogamicin (Mylotarg) | Policies naming J9203 |
| J9207 | On the list | Ixabepilone (Ixempra) | Policies naming J9207 |
| J9217 | On the list | Leuprolide acetate (for depot suspension) (Lupron Depot) | Policies naming J9217 |
| J9218 | On the list | Leuprolide acetate (Lupron) | Policies naming J9218 |
| J9219 | Not listed | Policies naming J9219 | |
| J9226 | On the list | Histrelin acetate (Supprelin LA) | Policies naming J9226 |
| J9228 | On the list | Ipilimumab (Yervoy) | Policies naming J9228 |
| J9262 | On the list | Omacetaxine mepesuccinate (Synribo) | Policies naming J9262 |
| J9264 | On the list | Paclitaxel protein-bound (Abraxane) | Policies naming J9264 |
| J9266 | On the list | Asparaginase (Oncaspar) | Policies naming J9266 |
| J9271 | On the list | Pembrolizumab (Keytruda) | Policies naming J9271 |
| J9285 | Not listed | Policies naming J9285 | |
| J9295 | Not listed | Policies naming J9295 | |
| J9299 | On the list | Nivolumab (Opdivo) | Policies naming J9299 |
| J9301 | On the list | Obinutuzumab (Gazyva) | Policies naming J9301 |
| J9302 | On the list | Ofatumumab (Arzerra) | Policies naming J9302 |
| J9303 | On the list | Panitumumab (Vectibix) | Policies naming J9303 |
| J9305 | On the list | Pemetrexed disodium (Alimta) | Policies naming J9305 |
| J9306 | On the list | Pertuzumab (Perjeta) | Policies naming J9306 |
| J9308 | On the list | Ramucirumab (Cyramza) | Policies naming J9308 |
| J9310 | Not listed | Policies naming J9310 | |
| J9315 | Not listed | Policies naming J9315 | |
| J9325 | On the list | Talimogene laherparepvec (Imlygic) | Policies naming J9325 |
| J9351 | Not listed | Policies naming J9351 | |
| J9352 | Not listed | Policies naming J9352 | |
| J9354 | On the list | Ado-trastuzumab emtansine (Kadcyla) | Policies naming J9354 |
| J9355 | Not listed | Policies naming J9355 | |
| J9400 | On the list | Ziv-aflibercept (Zaltrap) | Policies naming J9400 |
| J9999 | On the list | Lifileucel (Amtagvi) | Policies naming J9999 |
| Q0515 | Not listed | Policies naming Q0515 | |
| Q2041 | On the list | Axicabtagene Ciloleucel [Yescarta] | Policies naming Q2041 |
| Q2043 | On the list | Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion (Provenge) | Policies naming Q2043 |
| Q2049 | Not listed | Policies naming Q2049 | |
| Q2050 | Not listed | Policies naming Q2050 | |
| Q4074 | On the list | Iloprost (Ventavis) | Policies naming Q4074 |
| Q5101 | On the list | Filgrastim-sndz (Zarxio) | Policies naming Q5101 |
| Q5103 | On the list | Infliximab-dyyb (Inflectra) | Policies naming Q5103 |
| Q5104 | On the list | Infliximab-abda (Renflexis) | Policies naming Q5104 |
| Q5106 | On the list | Epoetin alfa-epbx (Retacrit) | Policies naming Q5106 |
| Q5108 | On the list | Pegfilgrastim-jmdb (Fulphila) | Policies naming Q5108 |
| Q5110 | On the list | Filgrastim-aafi (Nivestym) | Policies naming Q5110 |
| Q9993 | Not listed | Policies naming Q9993 | |
| Q9995 | Not listed | Policies naming Q9995 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list