Anthem Blue Cross Blue Shield of California prior authorization, page 71
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 |
|---|---|---|
| J2506 | Pegfilgrastim (Neulasta, Neulasta Onpro) - excludes biosimilar | California PPO Prior Authorization List, Pg 190 Original policy |
| J2820 | Sargramostim (Leukine) | California PPO Prior Authorization List, Pg 190 Original policy |
| J3262 | Tocilizumab (Actemra) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9033 | Bendamustine HCL (Treanda) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9034 | Bendamustine (Bendeka) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9035 | Avastin (bevacizumab) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9036 | Bendamustine (Belrapzo) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9301 | Obinutuzumab (Gazyva) | California PPO Prior Authorization List, Pg 190 Original policy |
| Q4081 | Epoetin alfa (for ESRD on dialysis) (Epogen, Procrit) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5101 | Filgrastim-sndz (Zarxio) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5105 | Epoetin alfa-epbx (Retacrit) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5106 | Epoetin alfa-epbx (Retacrit) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5108 | Pegfilgrastim-jmdb (Fulphila) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5110 | Filgrastim-aafi (Nivestym) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5111 | Pegfilgrastim-cbqv (Udenyca/Udenyca Onbody) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5115 | Tituximab-abbs (Truxima) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5119 | Rituximab-pvvr (Ruxience) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5120 | Pegfilgrastim-bmez, biosimilar (Ziextenzo) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5122 | Immune globulin (Nyvepria) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5125 | Filgrastim-ayow (Releuko) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5126 | Bevacizumab-maly (Alymsys) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5127 | Pegfilgrastim-fpgk (Stimufend) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5129 | Bevacizumab-adcd (Vegzelma) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5130 | Pegfilgrastim-pbbk (Fylnetra) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5133 | Tocilizumab-bavi (Tofidence) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5135 | Tocilizumab-aazg (Tyenne) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5136 | Denosumab-bbdz (Jubbonti) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5148 | Filgrastim-txid (Nypozi) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5156 | Tocilizumab-anoh (Avtozma) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5157 | Denosumab-bmwo (Osenvelt, Stoboclo) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5158 | Denosumab-bnht (Bomyntra, Conexxence) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5159 | Denosumab-dssb (Ospomyv, Xbryk) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5161 | Denosumab-kyqq (Aukelso, Bosaya) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5162 | Denosumab-nxxp (Bildyos, Bilprevda) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5166 | Denosumab-desu (Jubereq, Osvytri) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5167 | Denosumab-qbde (Enoby, Xtrenbo) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5169 | Pegfilgrastim-unne (Armlupeg) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5171 | Denosumab-mobz (Boncresa) | California PPO Prior Authorization List, Pg 193 Original policy |
| Q5172 | Filgrastim-laha (Filkri) | California PPO Prior Authorization List, Pg 193 Original policy |
| Q5173 | Denosumab-adet (Ponlimsi) | California PPO Prior Authorization List, Pg 193 Original policy |