Anthem Blue Cross Blue Shield of Colorado 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

Prior authorization codes
Code	Description	Source
J1956	Levofloxacin Injection	Colorado Prior Authorization List, Pg 157 Original policy
J1961	Injection, lenacapavir (only for use as HIV treatment), 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2170	INJECTION, MECASERMIN, 1 MG	Colorado Prior Authorization List, Pg 157 Original policy
J2182	Injection, mepolizumab, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2183	Injection, meropenem (WG Critical Care), not therapeutically equivalent to J2185, 100 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2184	Injection, meropenem (B. Braun), not therapeutically equivalent to J2185, 100 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2185	Injection, meropenem, 100 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2267	Injection, mirikizumab-mrkz, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2277	Injection, motixafortide, 0.25 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2278	Injection, ziconotide, 1 mcg	Colorado Prior Authorization List, Pg 157 Original policy
J2280	Injection, moxifloxacin, 100 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2281	Injection, moxifloxacin (Fresenius Kabi), not therapeutically equivalent to J2280, 100 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2323	Imjection, natalizumab, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2326	Injection, nusinersen, 0.1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2327	Injection, risankizumab-rzaa, intravenous, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2329	Injection, ublituximab-xiiy, 1mg	Colorado Prior Authorization List, Pg 157 Original policy
J2350	Injection, ocrelizumab, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2351	Injection, ocrelizumab, 1 mg and hyaluronidase-ocsq	Colorado Prior Authorization List, Pg 157 Original policy
J2353	Injection, octreotide, depot form for intramuscular injection, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2354	Injection, octreotide, non-depot form for subcutaneous or intravenous	Colorado Prior Authorization List, Pg 157 Original policy
J2356	Injection, tezepelumab-ekko, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2357	Omalizumab injection	Colorado Prior Authorization List, Pg 157 Original policy
J2502	Injection, pasireotide long acting, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2505	Injection, pegfilgrastim, 6 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2506	Injection, pegfilgrastim, excludes biosimilar, 0.5 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2507	Injection, pegloticase, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2508	Injection, pegunigalsidase alfa-iwxj, 1 mg	Colorado Prior Authorization List, Pg 157 Original policy
J2510	Penicillin G Procaine Inj	Colorado Prior Authorization List, Pg 157 Original policy
J2540	Penicillin G Potassium Inj	Colorado Prior Authorization List, Pg 158 Original policy
J2562	Injection, Plerixafor, 1 Mg	Colorado Prior Authorization List, Pg 158 Original policy
J2777	Injection, faricimab-svoa, 0.1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J2778	Injection, ranibizumab, 0.1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J2779	Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J2781	Injection, pegcetacoplan, intravitreal, 1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J2782	Injection, avacincaptad pegol, 0.1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J2786	Injection, reslizumab, 1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J2787	Riboflavin 5'-phosphate, ophthalmic solution (photrexa viscous/photrexa), up to 3 ml	Colorado Prior Authorization List, Pg 158 Original policy
J2793	Injection, Rilonacept, 1 Mg	Colorado Prior Authorization List, Pg 158 Original policy
J2796	Injection, Romiplostim, 10 Micrograms	Colorado Prior Authorization List, Pg 158 Original policy
J2802	Injection, romiplostim, 1 microgram	Colorado Prior Authorization List, Pg 158 Original policy
J2820	Sargramostim Injection	Colorado Prior Authorization List, Pg 158 Original policy
J2840	Injection, sebelipase alfa, 1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J2940	Injection, somatrem, 1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J2941	Injection, somatropin, 1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J2998	Injection, plasminogen, human-tvmh, 1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J3032	Injection, eptinezumab-jjmr, 1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J3055	Injection, talquetamab-tgvs, 0.25 mg	Colorado Prior Authorization List, Pg 158 Original policy
J3060	Injection, taliglucerace alfa, 10 units	Colorado Prior Authorization List, Pg 158 Original policy
J3111	Injection, romosozumab-aqqg, 1 mg	Colorado Prior Authorization List, Pg 158 Original policy
J3241	Injection, teprotumumab-trbw, 10 mg	Colorado Prior Authorization List, Pg 158 Original policy

Sources

Colorado Prior Authorization List