Anthem Blue Cross Blue Shield of Colorado prior authorization, page 69

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

Prior authorization codes
Code	Description	Source
J0690	Cefazolin Sodium Injection	Colorado Prior Authorization List, Pg 155 Original policy
J0696	Ceftriaxone Sodium Injection	Colorado Prior Authorization List, Pg 155 Original policy
J0698	Cefotaxime Sodium Injection	Colorado Prior Authorization List, Pg 155 Original policy
J0717	Injection, certolizumab pegol, 1 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administer	Colorado Prior Authorization List, Pg 155 Original policy
J0738	Injection, lenacapavir, 1 mg, FDA-approved prescription, only for use as HIV pre- exposure prophylaxis (PrEP) (not for use as treatment for HIV)	Colorado Prior Authorization List, Pg 155 Original policy
J0741	Injection, cabotegravir and rilpivirine, 2 mg/3 mg	Colorado Prior Authorization List, Pg 155 Original policy
J0743	Cilastatin Sodium Injection	Colorado Prior Authorization List, Pg 155 Original policy
J0744	Injection, ciprofloxacin for intravenous infusion, 200 mg	Colorado Prior Authorization List, Pg 155 Original policy
J0752	Oral, lenacapavir, 300 mg, FDA-approved prescription, only for use as HIV pre- exposure prophylaxis (PrEP) (not for use as treatment for HIV)	Colorado Prior Authorization List, Pg 155 Original policy
J0775	Injection, collagenase, clostridium histolyticum, 0.01 mg	Colorado Prior Authorization List, Pg 155 Original policy
J0791	Injection, crizanlizumab-tmca, 5 mg	Colorado Prior Authorization List, Pg 155 Original policy
J0800	Injection, corticotropin, up to 40 units	Colorado Prior Authorization List, Pg 155 Original policy
J0801	Injection, corticotropin (Acthar Gel), up to 40 units	Colorado Prior Authorization List, Pg 155 Original policy
J0802	Injection, corticotropin (ANI), up to 40 units	Colorado Prior Authorization List, Pg 155 Original policy
J0870	Injection, imetelstat, 1 mg	Colorado Prior Authorization List, Pg 155 Original policy
J0881	Injection, darbepoetin alfa, 1 mcg (non-ESRD use)	Colorado Prior Authorization List, Pg 155 Original policy
J0882	Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)	Colorado Prior Authorization List, Pg 155 Original policy
J0885	Injection, epoetin alfa, (for non-ESRD use), 1000 units	Colorado Prior Authorization List, Pg 155 Original policy
J0887	Injection, epoetin beta, 1 microgram, (for esrd on dialysis)	Colorado Prior Authorization List, Pg 155 Original policy
J0888	Injectin, epoetin beta, 1 microgram, (for non esrd use)	Colorado Prior Authorization List, Pg 155 Original policy
J0896	Injection, luspatercept-aamt, 0.25 mg	Colorado Prior Authorization List, Pg 155 Original policy
J0897	Injection, denosumab, 1 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1072	Injection, testosterone cypionate (Azmiro), 1 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1073	Testosterone pellet, implant, 75 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1203	Injection, cipaglucosidase alfa-atga, 5 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1290	Injection, ecallantide, 1 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1299	Injection, eculizumab, 2 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1300	Injection, eculizumab, 10 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1301	Injection, edaravone, 1 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1302	Injection, sutimlimab-jome, 10 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1303	Injection, ravulizumab-cwvz, 10 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1304	Injection, tofersen, 1 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1305	Injection, evinacumab-dgnb, 5 mg	Colorado Prior Authorization List, Pg 155 Original policy
J1306	Injection, inclisiran, 1 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1307	Injection, crovalimab-akkz, 10 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1322	Injection, elosulfase alfa, 1mg	Colorado Prior Authorization List, Pg 156 Original policy
J1323	Injection, elranatamab-bcmm, 1 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1325	Epoprostenol Injection	Colorado Prior Authorization List, Pg 156 Original policy
J1326	Injection, zolbetuximab-clzb, 2 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1335	Injection, ertapenem sodium, 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1411	Injection, etranacogene dezaparvovec-drlb, per therapeutic dose	Colorado Prior Authorization List, Pg 156 Original policy
J1412	Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes	Colorado Prior Authorization List, Pg 156 Original policy
J1413	Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose	Colorado Prior Authorization List, Pg 156 Original policy
J1414	Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose	Colorado Prior Authorization List, Pg 156 Original policy
J1426	Injection, casimersen, 10 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1427	Injection, viltolarsen, 10 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1428	Injection, eteplirsen, 10 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1429	Injection, golodirsen, 10 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1437	Injection, ferric derisomaltose, 10 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1438	Etanercept Injection	Colorado Prior Authorization List, Pg 156 Original policy

Sources

Colorado Prior Authorization List