Anthem Blue Cross Blue Shield of Georgia prior authorization, page 34
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
| Code | Description | Source |
|---|---|---|
| J9203 | Injection, gemtuzumab ozogamicin, 0.1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9207 | Injection, ixabepilone, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9216 | Injection, interferon, gamma-1B, 3 million units | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9223 | Injection, lurbinectedin, 0.1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9227 | Injection, isatuximab-irfc, 10 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9228 | Injection, ipilimumab, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9229 | Injection, inotuzumab ozogamicin, 0.1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9262 | Injection, omacetaxine mepesuccinate, 0.01 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9264 | Injection, paclitaxel protein-bound particles, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9269 | Injection, tagraxofusp-erzs, 10 micrograms | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9271 | Injection, pembrolizumab, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9272 | Injection, dostarlimab-gxly, 10 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9273 | Injection, tisotumab vedotin-tftv, 1 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9274 | Injection, tebentafusp-tebn, 1 microgram | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9275 | Injection, cosibelimab-ipdl, 2 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9276 | Injection, zanidatamab-hrii, 2 mg | Standard Local Prior Authorization Code List, Pg 88 Original policy |
| J9277 | Injection, pembrolizumab, 1 mg and berahyaluronidase alfa-pmph | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9281 | Mitomycin pyelocalyceal instillation, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9282 | Mitomycin, intravesical instillation, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9286 | Injection, glofitamab-gxbm, 2.5 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9289 | Injection, nivolumab, 2 mg and hyaluronidase-nvhy | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9292 | Injection, pemetrexed (Avyxa), not therapeutically equivalent to J9305, 10 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9294 | Injection, pemetrexed (Hospira), not therapeutically equivalent to J9305, 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9296 | Injection, pemetrexed (Accord), not therapeutically equivalent to J9305, 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9297 | Injection, pemetrexed (sandoz), not therapeutically equivalent to j9305, 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9298 | Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9299 | Injection, nivolumab, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9302 | Injection, ofatumumab, 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9303 | Injection, panitumumab, 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9304 | Injection, pemetrexed, 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9306 | Injection, pertuzumab, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9308 | Injection, ramucirumab, 5 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9309 | Injection, polatuzumab vedotin-piiq, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9314 | Injection, pemetrexed (Teva), not therapeutically equivalent to J9305, 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9316 | Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9317 | Injection, sacituzumab govitecan-hziy, 2.5 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9318 | Injection, romidepsin, nonlyophilized, 0.1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9319 | Injection, romidepsin, lyophilized, 0.1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9321 | Injection, epcoritamab-bysp, 0.16 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9322 | Injection, pemetrexed (BluePoint), not therapeutically equivalent to J9305, 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9323 | Injection, pemetrexed (hospira) not therapeutically equivalent to j9305, 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9324 | Injection, pemetrexed (Pemrydi RTU), 10 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9325 | Injection, talimogene laherparepvec, per 1 million plaque forming units | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9326 | Injection, telisotuzumab vedotin-tllv, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9329 | Injection, tislelizumab-jsgr, 1mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9331 | Injection, sirolimus protein-bound particles, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9345 | Injection, retifanlimab-dlwr, 1 mg [Zynyz] | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9347 | Injection, tremelimumab-actl, 1 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9348 | Injection, naxitamab-gqgk, 1 m | Standard Local Prior Authorization Code List, Pg 89 Original policy |
| J9349 | Injection, tafasitamab-cxix, 2 mg | Standard Local Prior Authorization Code List, Pg 89 Original policy |