Anthem Blue Cross Blue Shield of California prior authorization, page 70
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 |
|---|---|---|
| Q5143 | Adalimumab-adbm (Cyltezo) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5134 | Natalizumab-sztn (Tyruko) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5144 | Adalimumab-aacf (Idacio) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5145 | Adalimumab-afzb (Abrilada) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5147 | Aflibercept-ayyh (Pavblu) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5149 | Aflibercept-abzv (Enzeevu) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5150 | Aflibercept-mrbb (Ahzantive) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5151 | Eculizumab-aagh (Epysqi) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5152 | Eculizumab-aeeb (Bkemv) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5153 | Aflibercept-yszy (Opuviz) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5154 | Omalizumab - igec (Omlyclo) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5155 | Aflibercept-jbvf (Yesafili) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5164 | Ustekinumab-hmny (Starjemza) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5168 | Ranibizumab-leyk (Nufymco) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5170 | Aflibercept-boav (Eydenzelt) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q9996 | Ustekinumab-ttwe (Pyzchiva) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q9997 | Ustekinumab-ttwe (Pyzchiva IV) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q9998 | Ustekinumab-aekn (Selarsdi) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q9999 | Ustekinumab-aauz (Otulfi) | California PPO Prior Authorization List, Pg 187 Original policy |
| S9560 | Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | California PPO Prior Authorization List, Pg 187 Original policy |
| J0565 | Bezlotoxumab (Zinplava) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0641 | Levoleucovorin (Fusilev) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0642 | Levoleucovorin (Khapzory) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0881 | Darbepoetin Alfa (Aranesp) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0882 | Darbepoetin Alfa (Aranesp) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0896 | Luspatercept (Reblozyl) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0897 | Denosumab (Prolia, Xgeva) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1442 | Filgrastim (Neupogen) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1447 | Tbo-Filgrastim (Granix) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1449 | Eflapegrastim-xnst (Rolvedon) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1459 | Immune globulin, IV, non-lyophilized (Privigen) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1551 | Immuno globulin (Cutaquig) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1553 | Immune globulin intravenous, human-dira (Yimmugo) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1554 | Immune Globulin (Human) IV (Asceniv) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1555 | Immune Globulin (Cuvitru) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1556 | Immune Globulin (Bivigam) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1557 | Immune Globulin (Gammaplex) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1558 | Immune Globulin (Human)-klhw (Xembify) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1559 | Immune Globulin (Human) Subcutaneous (Hizentra) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1561 | Immune Globulin (Human) IV or Subcutaneous (Gamunex- C/Gammaked) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1566 | Immune Globulin (Human) IV (Gammagard SD) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1568 | Immune Globulin (Human) IV (Octagam) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1569 | Immune Globulin (Gammagard Liquid, Gammagard Liquid ERC) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1572 | Immune Globulin (Human) IV (Flebogamma) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1575 | Immune Globulin (Human) IV (HyQvia) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1576 | Immune Globulin (Human) IV (Panzyga) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1930 | Lanreotide (Somatuline Depot) | California PPO Prior Authorization List, Pg 190 Original policy |
| J1932 | Lanreotide (cipla) | California PPO Prior Authorization List, Pg 190 Original policy |
| J2353 | Octreotide, depot form (Sandostatin LAR depot) | California PPO Prior Authorization List, Pg 190 Original policy |
| J2354 | Octreotide (Sandostatin) | California PPO Prior Authorization List, Pg 190 Original policy |