Anthem Blue Cross Blue Shield of Georgia policy
Medicare Advantage 2018 Precertification Requirements
Medicare Advantage 2018 Precertification Requirements is a public Anthem Blue Cross Blue Shield of Georgia policy (effective Jan 1, 2018). It lists 158 CPT or HCPCS codes, 112 of them on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
- Effective
- Jan 1, 2018
- States
- CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, VA, WI
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of Georgia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Georgia policies |
|---|---|---|---|
| A9606 | On the list | Radium ra-223 dichloride, therapeutic, per microcurie | Policies naming A9606 |
| C9257 | On the list | Injection, bevacizumab, 0.25 mg | Policies naming C9257 |
| C9476 | Not listed | Policies naming C9476 | |
| C9483 | Not listed | Policies naming C9483 | |
| C9484 | Not listed | Policies naming C9484 | |
| C9485 | Not listed | Policies naming C9485 | |
| C9486 | Not listed | Policies naming C9486 | |
| C9487 | Not listed | Policies naming C9487 | |
| J0129 | On the list | Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) | Policies naming J0129 |
| J0135 | Not listed | Policies naming J0135 | |
| J0178 | On the list | Injection, aflibercept, 1 mg | Policies naming J0178 |
| J0202 | On the list | Injection, alemtuzumab, 1 mg | Policies naming J0202 |
| J0485 | On the list | Injection, belatacept, 1 mg | Policies naming J0485 |
| J0490 | On the list | Injection, belimumab, 10 mg | Policies naming J0490 |
| J0585 | On the list | Injection, Onabotulinumtoxina, 1 Unit | Policies naming J0585 |
| J0586 | On the list | Injection, Abobotulinumtoxina, 5 Units | Policies naming J0586 |
| J0587 | On the list | Injection, Rimabotulinumtoxinb, 100 Units | Policies naming J0587 |
| J0588 | On the list | Injection, incobotulinumtoxinA, 1 unit | Policies naming J0588 |
| J0881 | On the list | Injection, darbepoetin alfa, 1 mcg (non-ESRD use) | Policies naming J0881 |
| J0885 | On the list | Injection, epoetin alfa, (for non-ESRD use), 1000 units | Policies naming J0885 |
| J0888 | On the list | Injectin, epoetin beta, 1 microgram, (for non esrd use) | Policies naming J0888 |
| J0897 | On the list | Injection, denosumab, 1 mg | Policies naming J0897 |
| J1300 | Not listed | Policies naming J1300 | |
| J1325 | On the list | Injection, epoprostenol, 0.5 mg | Policies naming J1325 |
| J1438 | On the list | Injection, etanercept, 25 mg | Policies naming J1438 |
| J1442 | On the list | Injection, filgrastim (G-CSF), excludes biosimilars, 1 mcg | Policies naming J1442 |
| J1447 | On the list | Injection, tbo-filgrastim, 1 microgram | Policies naming J1447 |
| J1453 | Not listed | Policies naming J1453 | |
| J1459 | On the list | Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1459 |
| J1556 | On the list | Injection, immune globulin (Bivigam), 500 mg | Policies naming J1556 |
| J1557 | On the list | Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1557 |
| J1559 | On the list | Injection, immune globulin (Hizentra), 100 mg | Policies naming J1559 |
| J1561 | On the list | Injection, immune globulin, (Gamunex/Gamunex- C/Gammaked), nonlyophilized (e.g., liquid), 500 mg | Policies naming J1561 |
| J1562 | Not listed | Policies naming J1562 | |
| J1566 | On the list | Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg | Policies naming J1566 |
| J1568 | On the list | Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1568 |
| J1569 | On the list | Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg | Policies naming J1569 |
| J1572 | On the list | Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg | Policies naming J1572 |
| J1575 | On the list | Injection, immune globulin/hyaluronidase, 100 mg immuneglobulin | Policies naming J1575 |
| J1599 | Not listed | Policies naming J1599 | |
| J1602 | On the list | Injection, golimumab, 1 mg, for intravenous use | Policies naming J1602 |
| J1740 | Not listed | Policies naming J1740 | |
| J1745 | On the list | Injection, infliximab, excludes biosimilar, 10 mg | Policies naming J1745 |
| J1950 | On the list | Injection, leuprolide acetate (for depot suspension), per 3.75 mg | Policies naming J1950 |
| J2170 | On the list | Injection, mecasermin, 1 mg | Policies naming J2170 |
| J2182 | On the list | Injection, mepolizumab, 1 mg | Policies naming J2182 |
| J2278 | On the list | Injection, ziconotide, 1 mcg | Policies naming J2278 |
| J2323 | On the list | Imjection, natalizumab, 1 mg | Policies naming J2323 |
| J2353 | On the list | Injection, octreotide, depot form for intramuscular injection, 1 mg | Policies naming J2353 |
| J2354 | On the list | Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg | Policies naming J2354 |
| J2355 | Not listed | Policies naming J2355 | |
| J2357 | On the list | Injection, omalizumab, 5 mg | Policies naming J2357 |
| J2469 | Not listed | Policies naming J2469 | |
| J2503 | Not listed | Policies naming J2503 | |
| J2505 | Not listed | Policies naming J2505 | |
| J2507 | On the list | Injection, pegloticase, 1 mg | Policies naming J2507 |
| J2778 | On the list | Injection, ranibizumab, 0.1 mg | Policies naming J2778 |
| J2786 | On the list | Injection, reslizumab, 1 mg | Policies naming J2786 |
| J2796 | Not listed | Policies naming J2796 | |
| J2820 | On the list | Injection, sargramostim (GM-CSF), 50 mcg | Policies naming J2820 |
| J2860 | Not listed | Policies naming J2860 | |
| J2941 | On the list | Injection, somatropin, 1 mg | Policies naming J2941 |
| J3262 | On the list | Injection, tocilizumab, 1 mg | Policies naming J3262 |
| J3285 | On the list | Injection, treprostinil, 1 mg | Policies naming J3285 |
| J3380 | On the list | Injection, vedolizumab, 1 mg | Policies naming J3380 |
| J3489 | On the list | Injection, zoledronic acid, 1 mg | Policies naming J3489 |
| J3490 | On the list | Unclassified drugs | Policies naming J3490 |
| J3590 | On the list | Unclassified Biologics | Policies naming J3590 |
| J7175 | On the list | Injection, Factor X, (human), 1 IU | Policies naming J7175 |
| J7178 | On the list | Injection, human fibrinogen concentrate, not otherwise specified, 1 mg | Policies naming J7178 |
| J7179 | On the list | Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU VWF:Rco | Policies naming J7179 |
| J7180 | On the list | Injection, Factor XIII (antihemophilic factor, human), 1 IU | Policies naming J7180 |
| J7181 | On the list | Injection, Factor XIII A-subunit, (recombinant), per IU | Policies naming J7181 |
| J7182 | On the list | Injection, Factor VIII, (antihemophilic factor, recombinant), (NovoEight), per IU | Policies naming J7182 |
| J7183 | On the list | Injection, von Willebrand factor complex (human), Wilate, 1 IU VWF:RCO | Policies naming J7183 |
| J7185 | On the list | Injection, Factor VIII (antihemophilic factor, recombinant) (Xyntha), per IU | Policies naming J7185 |
| J7186 | On the list | Injection, antihemophilic Factor VIII/von Willebrand factor complex (human), per Factor VIII IU | Policies naming J7186 |
| J7187 | On the list | Injection, von Willebrand factor complex (Humate- P), per IU VWF:RCO | Policies naming J7187 |
| J7188 | On the list | Injection, Factor VIII (antihemophilic factor, recombinant) (Obizur), per IU | Policies naming J7188 |
| J7189 | On the list | Factor VIIa (antihemophilic factor, recombinant), (NovoSeven RT), 1 mcg | Policies naming J7189 |
| J7190 | On the list | Factor VIII (antihemophilic factor, human) per IU | Policies naming J7190 |
| J7191 | On the list | Factor VIII (antihemophilic factor (porcine)), per IU | Policies naming J7191 |
| J7192 | On the list | Factor VIII (antihemophilic factor, recombinant) per IU, not otherwise specified | Policies naming J7192 |
| J7193 | On the list | Factor IX (antihemophilic factor, purified, nonrecombinant) per IU | Policies naming J7193 |
| J7194 | On the list | Factor IX complex, per IU | Policies naming J7194 |
| J7195 | On the list | Injection, Factor IX (antihemophilic factor, recombinant) per IU, not otherwise specified | Policies naming J7195 |
| J7198 | On the list | Antiinhibitor, per IU | Policies naming J7198 |
| J7199 | Not listed | Policies naming J7199 | |
| J7200 | On the list | Injection, Factor IX, (antihemophilic factor, recombinant), Rixubis, per IU | Policies naming J7200 |
| J7201 | On the list | Injection, Factor IX, Fc fusion protein, (recombinant), Alprolix, 1 IU | Policies naming J7201 |
| J7202 | On the list | Injection, Factor IX, albumin fusion protein, (recombinant), Idelvion, 1 IU | Policies naming J7202 |
| J7205 | On the list | Injection, Factor VIII Fc fusion protein (recombinant), per IU | Policies naming J7205 |
| J7207 | On the list | Injection, Factor VIII, (antihemophilic factor, recombinant), PEGylated, 1 IU | Policies naming J7207 |
| J7209 | On the list | Injection, Factor VIII, (antihemophilic factor, recombinant), (Nuwiq), 1 IU | Policies naming J7209 |
| J7311 | On the list | Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mg | Policies naming J7311 |
| J7312 | On the list | Injection, dexamethasone, intravitreal implant, 0.1 mg | Policies naming J7312 |
| J7313 | On the list | Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg | Policies naming J7313 |
| J7316 | Not listed | Policies naming J7316 | |
| J7320 | Not listed | Policies naming J7320 | |
| J7321 | Not listed | Policies naming J7321 | |
| J7322 | Not listed | Policies naming J7322 | |
| J7323 | Not listed | Policies naming J7323 | |
| J7324 | Not listed | Policies naming J7324 | |
| J7325 | Not listed | Policies naming J7325 | |
| J7327 | Not listed | Policies naming J7327 | |
| J7328 | Not listed | Policies naming J7328 | |
| J7340 | On the list | Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml | Policies naming J7340 |
| J7686 | On the list | Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg | Policies naming J7686 |
| J9010 | Not listed | Policies naming J9010 | |
| J9015 | On the list | Injection, aldesleukin, per single use vial | Policies naming J9015 |
| J9025 | Not listed | Policies naming J9025 | |
| J9034 | On the list | Injection, bendamustine hcl (bendeka), 1 mg | Policies naming J9034 |
| J9035 | On the list | Injection, bevacizumab, 10 mg | Policies naming J9035 |
| J9039 | On the list | Injection, blinatumomab, 1 microgram | Policies naming J9039 |
| J9042 | On the list | Injection, brentuximab vedotin, 1 mg | Policies naming J9042 |
| J9043 | On the list | Injection, cabazitaxel, 1 mg | Policies naming J9043 |
| J9047 | On the list | Injection, carfilzomib, 1 mg | Policies naming J9047 |
| J9055 | On the list | Injection, cetuximab, 10 mg | Policies naming J9055 |
| J9145 | On the list | Injection, daratumumab, 10 mg | Policies naming J9145 |
| J9155 | Not listed | Policies naming J9155 | |
| J9176 | On the list | Injection, elotuzumab, 1 mg | Policies naming J9176 |
| J9179 | On the list | Injection, eribulin mesylate, 0.1 mg | Policies naming J9179 |
| J9202 | On the list | Goserelin acetate implant, per 3.6 mg | Policies naming J9202 |
| J9207 | On the list | Injection, ixabepilone, 1 mg | Policies naming J9207 |
| J9216 | On the list | Injection, interferon, gamma-1B, 3 million units | Policies naming J9216 |
| J9217 | On the list | Leuprolide acetate (for depot suspension), 7.5 mg | Policies naming J9217 |
| J9218 | Not listed | Policies naming J9218 | |
| J9219 | Not listed | Policies naming J9219 | |
| J9228 | On the list | Injection, ipilimumab, 1 mg | Policies naming J9228 |
| J9262 | On the list | Injection, omacetaxine mepesuccinate, 0.01 mg | Policies naming J9262 |
| J9264 | On the list | Injection, paclitaxel protein-bound particles, 1 mg | Policies naming J9264 |
| J9266 | On the list | Injection, pegaspargase, per single dose vial | Policies naming J9266 |
| J9271 | On the list | Injection, pembrolizumab, 1 mg | Policies naming J9271 |
| J9295 | Not listed | Policies naming J9295 | |
| J9299 | On the list | Injection, nivolumab, 1 mg | Policies naming J9299 |
| J9301 | On the list | Injection, obinutuzumab, 10 mg | Policies naming J9301 |
| J9302 | On the list | Injection, ofatumumab, 10 mg | Policies naming J9302 |
| J9303 | On the list | Injection, panitumumab, 10 mg | Policies naming J9303 |
| J9305 | On the list | Injection, pemetrexed, NOS, 10 mg | Policies naming J9305 |
| J9306 | On the list | Injection, pertuzumab, 1 mg | Policies naming J9306 |
| J9308 | On the list | Injection, ramucirumab, 5 mg | Policies naming J9308 |
| J9310 | Not listed | Policies naming J9310 | |
| J9315 | Not listed | Policies naming J9315 | |
| J9325 | On the list | Injection, talimogene laherparepvec, per 1 million plaque forming units | Policies naming J9325 |
| J9330 | Not listed | Policies naming J9330 | |
| J9351 | Not listed | Policies naming J9351 | |
| J9352 | Not listed | Policies naming J9352 | |
| J9354 | On the list | Injection, ado-trastuzumab emtansine, 1 mg | Policies naming J9354 |
| J9355 | Not listed | Policies naming J9355 | |
| J9400 | On the list | Injection, ziv-aflibercept, 1 mg | Policies naming J9400 |
| J9999 | Not listed | Policies naming J9999 | |
| Q0515 | Not listed | Policies naming Q0515 | |
| Q2043 | On the list | Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion | Policies naming Q2043 |
| Q2049 | Not listed | Policies naming Q2049 | |
| Q2050 | Not listed | Policies naming Q2050 | |
| Q4074 | Not listed | Policies naming Q4074 | |
| Q5101 | On the list | Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 mcg | Policies naming Q5101 |
| Q5102 | Not listed | Policies naming Q5102 |
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list