Anthem Blue Cross Blue Shield of California 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
| Code | Description | Source |
|---|---|---|
| J9266 | Asparaginase (Oncaspar) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9269 | Tagraxofusp-erzs (Elzonris) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9271 | Pembrolizumab (Keytruda) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9272 | Dostarlimab (Jemperli) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9273 | Tisotumab vedotin-tftv (Tivdak) | California PPO Prior Authorization List, Pg 166 Original policy |
| J9274 | Tebentafusp-tebn (Kimmtrak) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9275 | Cosibelimab‑ipdl (Unloxcyt) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9276 | Zanidatamab-hrii (Ziihera) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9277 | Pembrolizumab and berahyaluronidase alfa-pmph (Keytruda Qlex) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9281 | Mitomycin pyelocalyceal instillation, 1 mg (Jelmyto) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9289 | Nivolumab hyaluronidase‑nvhy (Opdivo Qvantig) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9292 | Pemetrexed dipotassium (Axtle) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9294 | Pemetrexed disodium (Hospira), not therapeutically equivalent to J9305 | California PPO Prior Authorization List, Pg 167 Original policy |
| J9296 | Pemetrexed disodium (Accord), not therapeutically equivalent to J9305 | California PPO Prior Authorization List, Pg 167 Original policy |
| J9297 | Pemetrexed disodium (Sandoz), not therapeutically equivalent to J9305 | California PPO Prior Authorization List, Pg 167 Original policy |
| J9298 | Nivolumab and relatlimab-rmbw (Opdualag) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9299 | Nivolumab (Opdivo) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9302 | Ofatumumab (Arzerra) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9303 | Panitumumab (Vectibix) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9304 | Pemetrexed (Pemfexy) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9305 | Pemetrexed disodium (Alimta) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9306 | Pertuzumab (Perjeta) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9308 | Ramucirumab (Cyramza) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9309 | Polatuzumab vedotin-piiq (Polivy) | California PPO Prior Authorization List, Pg 167 Original policy |
| J9314 | Pemetrexed (Teva), not therapeutically equivalent to J9305 | California PPO Prior Authorization List, Pg 168 Original policy |
| J9316 | Sacituzumab govitecan-hziy, 10 mg (Phesgo) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9317 | Sacituzumab govitecan-hziy, 10 mg (Trodelvy) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9318 | Romidepsin (Istodax) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9319 | Romidepsin (Istodax) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9321 | Epcoritamab-bysp (Epkinly) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9322 | Pemetrexed (Bluepoint), not therapeutically equivalent to J9305 | California PPO Prior Authorization List, Pg 168 Original policy |
| J9323 | Pemetrexed ditromethamine | California PPO Prior Authorization List, Pg 168 Original policy |
| J9324 | Pemetrexed (Pemrydi RTU) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9325 | Talimogene laherparepvec (Imlygic) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9326 | Telisotuzumab vedotin-tllv (Emrelis) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9329 | Tislelizumab-jsgr (Tevimbra) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9331 | Sirolimus albumin bound (Fyarro) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9345 | Retifanlimab-dlwr (Zynyz) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9347 | Tremelimumab-actl (Imjudo) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9348 | Naxitamab-gqgk (Danyelza) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9349 | Injection, tafasitamab-cxix, 2 mg (Monjuvi) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9350 | Mosunetuzumab-axgb (Lunsumio) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9353 | Margetuximab-cmkb (Margenza) | California PPO Prior Authorization List, Pg 168 Original policy |
| J9354 | Ado-trastuzumab emtansine (Kadcyla) | California PPO Prior Authorization List, Pg 169 Original policy |
| J9358 | Fam-trastuzumab deruxtecan-nxki (Enhertu) | California PPO Prior Authorization List, Pg 169 Original policy |
| J9359 | Loncastuximab tesirine-lpyl (Zynlonta) | California PPO Prior Authorization List, Pg 169 Original policy |
| J9361 | Efbemalenograstim alfa-vuxw (Ryzneuta) | California PPO Prior Authorization List, Pg 169 Original policy |
| J9380 | Teclistamab-cqyv (Tecvayli) | California PPO Prior Authorization List, Pg 169 Original policy |
| J9382 | Zenocutuzumab-zbco (Bizengri) | California PPO Prior Authorization List, Pg 169 Original policy |
| J9400 | Ziv-aflibercept (Zaltrap) | California PPO Prior Authorization List, Pg 169 Original policy |