Anthem Blue Cross Blue Shield of Colorado 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

Prior authorization codes
Code	Description	Source
J1439	Injection, ferric carboxymaltose, 1mg	Colorado Prior Authorization List, Pg 156 Original policy
J1440	Fecal microbiota, live - jslm, 1 ml	Colorado Prior Authorization List, Pg 156 Original policy
J1442	5G-CSFexcludes biosimilars, 1 microgram	Colorado Prior Authorization List, Pg 156 Original policy
J1447	Injection, tbo-filgrastim, 1 microgram	Colorado Prior Authorization List, Pg 156 Original policy
J1448	Injection, trilaciclib, 1 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1449	Injection, eflapegrastim-xnst, 0.1 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1450	Fluconazole	Colorado Prior Authorization List, Pg 156 Original policy
J1454	Injection, fosnetupitant 235 mg and palonosetron 0.25 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1458	INJECTION, GALSULFASE, 1 MG	Colorado Prior Authorization List, Pg 156 Original policy
J1459	Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1460	Gamma Globulin 1 Cc Inj	Colorado Prior Authorization List, Pg 156 Original policy
J1551	Injection, immune globulin (cutaquig), 100 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1552	Injection, immune globulin (alyglo), 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1554	Injection, immune globulin (asceniv), 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1555	Injection, immune globulin (Cuvitru), 100 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1556	Injection, immune globulin (bivigam), 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1557	Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1558	Injection, immune globulin (xembify), 100 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1559	Injection, immune globulin (hizentra), 100 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1560	Gamma Globulin > 10 Cc Inj	Colorado Prior Authorization List, Pg 156 Original policy
J1561	Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1565	Rsv-Ivig	Colorado Prior Authorization List, Pg 156 Original policy
J1566	Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1568	Injection, immune globulin, (octagam), intravenous, non-lyophilized (e.g.	Colorado Prior Authorization List, Pg 156 Original policy
J1569	Injection, immune globulin, (gammagard liquid/gammagard liquid erc), 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1572	Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg	Colorado Prior Authorization List, Pg 156 Original policy
J1575	Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immuneglobulin	Colorado Prior Authorization List, Pg 157 Original policy
J1576	Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1595	Injection, glatiramer acetate, 20 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1599	Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1602	Injection, golimumab, 1 mg, for intravenous use	Colorado Prior Authorization List, Pg 157 Original policy
J1628	Injection, guselkumab, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1632	Injection, brexanolone, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1743	Injection, idursulfase, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1744	Injection, icatibant, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1745	Injection, infliximab, excludes biosimilar, 10 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1746	Injection, ibalizumab-uiyk, 10 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1747	Injection, spesolimab-sbzo, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1748	Injection, infliximab-dyyb (Zymfentra), 10 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1786	Injection, imiglucerase, 10 units	Colorado Prior Authorization List, Pg 157 Original policy
J1809	Injection, fosdenopterin, 0.1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1823	Injection, inebilizumab-cdon, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1826	Injection, interferon beta-1a, 30 mcg	Colorado Prior Authorization List, Pg 157 Original policy
J1830	Interferon Beta-1b / .25 Mg	Colorado Prior Authorization List, Pg 157 Original policy
J1930	Injection, lanreotide, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1931	Laronidase injection	Colorado Prior Authorization List, Pg 157 Original policy
J1932	Injection, lanreotide, (cipla), 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J1950	Leuprolide Acetate /3.75 Mg	Colorado Prior Authorization List, Pg 157 Original policy
J1951	Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 m	Colorado Prior Authorization List, Pg 157 Original policy
J1954	Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg	Colorado Prior Authorization List, Pg 157 Original policy

Sources

Colorado Prior Authorization List