Anthem Blue Cross Blue Shield of California 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
| Code | Description | Source |
|---|---|---|
| J2277 | Motixafortide (Aphexda) | California PPO Prior Authorization List, Pg 164 Original policy |
| J2787 | Riboflavin 5'-phosphate, ophthalmic solution, up to 3 mL [Photrexa, Photrexa Viscous] | California PPO Prior Authorization List, Pg 164 Original policy |
| J2802 | Romiplostim (Nplate) | California PPO Prior Authorization List, Pg 164 Original policy |
| J3055 | Talquetamab-tgvs (Talvey) | California PPO Prior Authorization List, Pg 164 Original policy |
| J3263 | Toripalimab-tpzi (Loqtorzi) | California PPO Prior Authorization List, Pg 164 Original policy |
| J3315 | Triptorelin pamoate (Trelstar, Trelstar Depot, Trelstar LA) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9286 | Glofitamab-gxbm (Columvi) | California PPO Prior Authorization List, Pg 164 Original policy |
| J7330 | Autologous cultured chondrocytes, implant | California PPO Prior Authorization List, Pg 164 Original policy |
| J9011 | Datopotamab deruxtecan‑dlnk (Datroway) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9015 | Aldesleukin (Proleukin) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9021 | Asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9022 | Atezolizumab (Tecentriq) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9023 | Avelumab (Bavencio) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9024 | Atezolizumab and hyaluronidase-tqjs (Tecentric Hybreza) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9028 | Nogapendekin alfa inbekicept-pmln (Anktiva) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9026 | Tarlatamab-dlle (Imdelltra) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9029 | Nadofaragene firadenovec-vncg (Adstiladrin) | California PPO Prior Authorization List, Pg 164 Original policy |
| J9032 | Belinostat (Beleodaq) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9038 | Axatilmab-csfr (Niktimvo) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9039 | Blinatumomab (Blincyto) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9042 | Brentuximab vedotin (Adcetris) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9043 | Cabazitaxel (Jevtana) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9047 | Carfilzomib (Kyprolis) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9053 | Belantamab mafodotin-blmf (Blenrep) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9055 | Cetuximab (Erbitux) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9056 | Bendamustine (Vivimusta) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9057 | Copanlisib HCl (Aliqopa) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9061 | Amivantamab-ymoiw (Rybrevant) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9062 | Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9063 | Mirvetuximab (Elahere) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9064 | Cabazitaxel (Sandoz), not therapeutically equivalent to J9043 | California PPO Prior Authorization List, Pg 165 Original policy |
| J9118 | Calaspargase pegol-mknl (Asparlas) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9119 | Cemiplimab-rwlc (Libtayo) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9144 | Daratumumab, 10 mg and hyaluronidase-fih (Darzalex Faspro) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9145 | Daratumumab (Darzalex) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9161 | Denileukin diftitox-cxdl (Lymphir) | California PPO Prior Authorization List, Pg 165 Original policy |
| J9173 | Durvalumab (Imfinzi) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9176 | Elotuzumab (Empliciti) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9177 | Enfortumab vedotin-ejfv (Padcev) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9179 | Eribulin mesylate (Halaven) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9183 | Gemcitabine intravescial system (Inlexzo) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9203 | Gemtuzumab ozogamicin (Mylotarg) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9207 | Ixabepilone (Ixempra) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9216 | Interferon Gamma-1b (Actimmune) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9223 | Sacituzumab govitecan-hziy, 10 mg (Zepzelca) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9227 | Injection, isatuximab-irfc, 10 mg (Sarclisa) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9228 | Ipilimumab (Yervoy) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9229 | Inotuzumab Ozogamicin (Besponsa) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9262 | Omacetaxine mepesuccinate (Synribo) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9264 | Paclitaxel protein-bound (Abraxane) | California PPO Prior Authorization List, Pg 166 Original policy |