Anthem Blue Cross Blue Shield of Colorado prior authorization, page 75

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
J9306	Injection, pertuzumab, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9308	Injection, ramucirumab, 5 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9309	Injection, polatuzumab vedotin-piiq, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9312	Injection, rituximab, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9314	Injection, pemetrexed (Teva), not therapeutically equivalent to J9305, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9316	Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9317	Injection, sacituzumab govitecan-hziy, 2.5 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9318	Injection, romidepsin, nonlyophilized, 0.1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9319	Injection, romidepsin, lyophilized, 0.1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9321	Injection, epcoritamab-bysp, 0.16 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9322	Injection, pemetrexed (BluePoint), not therapeutically equivalent to J9305, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9323	Injection, pemetrexed (hospira) not therapeutically equivalent to j9305, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9324	Injection, pemetrexed (pemrydi rtu), 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9325	Injection, talimogene laherparepvec, per 1 million plaque forming units	Colorado Prior Authorization List, Pg 161 Original policy
J9326	Injection, telisotuzumab vedotin-tllv, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9329	Injection, tislelizumab-jsgr, 1mg	Colorado Prior Authorization List, Pg 161 Original policy
J9331	Injection, sirolimus protein-bound particles, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9332	Injection, efgartigimod alfa-fcab, 2mg	Colorado Prior Authorization List, Pg 161 Original policy
J9333	Injection, rozanolixizumab-noli, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9334	Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc	Colorado Prior Authorization List, Pg 161 Original policy
J9345	Injection, retifanlimab-dlwr, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9347	Injection, tremelimumab-actl, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9348	Injection, naxitamab-gqgk, 1 m	Colorado Prior Authorization List, Pg 161 Original policy
J9349	Injection, tafasitamab-cxix, 2 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9350	Injection, mosunetuzumab-axgb, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9353	Injection, margetuximab-cmkb, 5 m	Colorado Prior Authorization List, Pg 161 Original policy
J9354	Injection, ado-trastuzumab emtansine, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9358	Injection, fam-trastuzumab deruxtecan-nxki, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9359	Injection, loncastuximab tesirine-lpyl, 0.075 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9361	Injection, efbemalenograstim alfa-vuxw, 0.5 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9376	Injection, pozelimab-bbfg, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9380	Injection, teclistamab-cqyv, 0.5 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9381	Injection, teplizumab-mzwv, 5 mcg	Colorado Prior Authorization List, Pg 161 Original policy
J9382	Injection, zenocutuzumab-zbco, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9400	Injection, ziv-aflibercept, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9601	Injection, linvoseltamab-gcpt, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
K0010	Stnd Wt Frame Power Whlchr	Colorado Prior Authorization List, Pg 161 Original policy
K0011	Stnd Wt Pwr Whlchr W Control	Colorado Prior Authorization List, Pg 161 Original policy
K0012	Ltwt Portbl Power Whlchr	Colorado Prior Authorization List, Pg 161 Original policy
K0013	Custom motorized/power wheelchair base	Colorado Prior Authorization List, Pg 161 Original policy
K0014	Other Power Whlchr Base	Colorado Prior Authorization List, Pg 161 Original policy
K0800	POWER OPERATED VEHICLE, GROUP 1 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS	Colorado Prior Authorization List, Pg 162 Original policy
K0801	POWER OPERATED VEHICLE, GROUP 1 HEAVY DUTY, PATIENT WEIGHT CAPACITY, 301 TO 450 POUNDS	Colorado Prior Authorization List, Pg 162 Original policy
K0802	POWER OPERATED VEHICLE, GROUP 1 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS	Colorado Prior Authorization List, Pg 162 Original policy
K0806	POWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS	Colorado Prior Authorization List, Pg 162 Original policy
K0807	POWER OPERATED VEHICLE, GROUP 2 HEAVY DUTY, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS	Colorado Prior Authorization List, Pg 162 Original policy
K0808	POWER OPERATED VEHICLE, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS	Colorado Prior Authorization List, Pg 162 Original policy
K0812	POWER OPERATED VEHICLE, NOT OTHERWISE CLASSIFIED	Colorado Prior Authorization List, Pg 162 Original policy
K0813	POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300	Colorado Prior Authorization List, Pg 162 Original policy
K0814	POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS	Colorado Prior Authorization List, Pg 162 Original policy

Sources

Colorado Prior Authorization List