Anthem Blue Cross Blue Shield of Georgia prior authorization, page 50
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 |
|---|---|---|
| J0221 | Injection, alglucosidase alfa, (Lumizyme), 10 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0222 | Injection, patisiran, 0.1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0223 | Injection, givosiran, 0.5 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0224 | Injection, lumasiran, 0.5 m | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0225 | Injection, vutrisiran, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0256 | Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0257 | Injection, alpha 1 proteinase inhibitor (human), (GLASSIA), 10 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0485 | Injection, belatacept, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0490 | Injection, belimumab, 10 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0491 | Injection, anifrolumab-fnia, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0517 | Injection, benralizumab, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0565 | Injection, bezlotoxumab, 10 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0567 | Injection, cerliponase alfa, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0584 | Injection, burosumab-twza 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0585 | Injection, Onabotulinumtoxina, 1 Unit | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0586 | Injection, Abobotulinumtoxina, 5 Units | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0587 | Injection, Rimabotulinumtoxinb, 100 Units | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0588 | Injection, incobotulinumtoxinA, 1 unit | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0589 | Injection, daxibotulinumtoxina-lanm, 1 unit | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0593 | Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered) | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0596 | Injection, c1 esterase inhibitor (recombinant), ruconest, 10 units | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0597 | Injection, c-1 esterase inhibitor (human), berinert, 10 units | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0598 | Injection, c-1 esterase inhibitor (human), cinryze, 10 units | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0599 | Injection, C-1 esterase inhibitor (human), (Haegarda), 10 units | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0638 | Injection, canakinumab, 1 mg | Standard Local Prior Authorization Code List, Pg 120 Original policy |
| J0717 | Injection, certolizumab pegol, 1 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) | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J0738 | Injection, lenacapavir, 1 mg, FDA-approved prescription, only for use as HIV pre-exposure prophylaxis (PrEP) (not for use as treatment for HIV) | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J0741 | Injection, cabotegravir and rilpivirine, 2 mg/3 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J0752 | Oral, lenacapavir, 300 mg, FDA-approved prescription, only for use as HIV pre-exposure prophylaxis (PrEP) (not for use as treatment for HIV) | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J0775 | Injection, collagenase, clostridium histolyticum, 0.01 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J0791 | Injection, crizanlizumab-tmca, 5 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J0801 | Injection, corticotropin (Acthar Gel), up to 40 units | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J0802 | Injection, corticotropin (ANI), up to 40 units | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J0887 | Injection, epoetin beta, 1 microgram, (for esrd on dialysis) | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J0888 | Injectin, epoetin beta, 1 microgram, (for non esrd use) | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1072 | Injection, testosterone cypionate (Azmiro), 1 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1073 | Testosterone pellet, implant, 75 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1203 | Injection, cipaglucosidase alfa-atga, 5 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1289 | Injection, narsoplimab-wuug, 1 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1290 | Injection, ecallantide, 1 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1299 | Injection, eculizumab, 2 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1301 | Injection, edaravone, 1 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1302 | Injection, sutimlimab-jome, 10 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1303 | Injection, ravulizumab-cwvz, 10 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1304 | Injection, tofersen, 1 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1305 | Injection, evinacumab-dgnb, 5 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1306 | Injection, inclisiran, 1 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1307 | Injection, crovalimab-akkz, 10 mg(cid:9) | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1322 | Injection, elosulfase alfa, 1mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |
| J1325 | Injection, epoprostenol, 0.5 mg | Standard Local Prior Authorization Code List, Pg 121 Original policy |