Anthem Blue Cross Blue Shield of California prior authorization, page 66
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 |
|---|---|---|
| J0225 | Vutrisiran (Amvuttra) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0256 | Alpha 1 proteinase inhibitor (Aralast) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0257 | Alpha 1 proteinase inhibitor (Glassia) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0485 | Belatacept (Nulojix) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0490 | Belimumab (Benlysta IV) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0491 | Anifrolumab-fnia intravenous (IV) (Saphnelo) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0517 | Benralizumab (Fasenra) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0567 | Cerliponase Alfa (Brineura) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0584 | Burosumab-twza (Crysvita) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0585 | OnabotulinumtoxinA (Botox) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0586 | AbobotulinumtoxinA (Dysport) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0587 | RimabotulinumtoxinB (Myobloc) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0588 | IncobotulinumtoxinA (Xeomin) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0589 | DaxibotulinumtoxinA-lanm (Daxxify) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0593 | Lanadelumab-flyo (Takhzyro) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0596 | Recombinant C1 esterase inhibitor (Ruconest) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0597 | C1 esterase inhibitor (human) (Berinert) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0598 | C1 esterase inhibitor (human) (Cinryze) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0599 | C1 esterase inhibitor (human) (Haegarda) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0638 | Canakinumab (Ilaris) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0717 | Certolizumab pegol (Cimzia) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0775 | Clostridial collagenase histolyticum (Xiaflex) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0791 | Crizanlizumab-tmca (Adakveo) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0801 | Corticotropin (Acthar Gel) | California PPO Prior Authorization List, Pg 177 Original policy |
| J0802 | Corticotropin (ANI) | California PPO Prior Authorization List, Pg 178 Original policy |
| J0885 | Injection, epoetin alfa (for non-ESRD use), 1000 units (Epogen, Procrit) | California PPO Prior Authorization List, Pg 178 Original policy |
| J0887 | Epoetin beta (Mircera) | California PPO Prior Authorization List, Pg 178 Original policy |
| J0888 | Epoetin beta (Mircera) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1203 | Cipaglucosidase alfa-atga (Pombiliti) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1289 | Narsoplimab-wuug (Yartemlea) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1290 | Ecallantide (Kalbitor) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1299 | Eculizumab (Soliris) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1301 | Edaravone (Radicava) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1302 | Sutimlimab-jome (Enjaymo) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1303 | Ravulizumab-cwvz (Ultomiris) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1304 | Tofersen (Qalsody) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1305 | Evinacumab (Evkeeza) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1306 | Inclisiran (Leqvio) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1307 | Crovalimab-akkz (Piasky) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1322 | Elosulfase Alfa (Vimizim) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1325 | Epoprostenol (Flolan) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1426 | Casimersen (Amondys 45) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1427 | Viltolarsen (Viltepso) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1428 | Eteplirsen (Exondys 51) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1429 | Golodirsen (Vyondys 53) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1437 | Injection, ferric derisomaltose, 10 mg (Monoferric) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1438 | Etanercept (Enbrel) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1439 | Injection, ferric carboxymaltose, 1 mg (Injectafer) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1440 | Fecal microbiota, live - jslm (Rebyota) | California PPO Prior Authorization List, Pg 178 Original policy |
| J1458 | Galsulfase (Naglazyme) | California PPO Prior Authorization List, Pg 179 Original policy |