Anthem Blue Cross Blue Shield of Georgia prior authorization, page 51

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
J1426	Injection, casimersen, 10 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1427	Injection, viltolarsen, 10 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1428	Injection, eteplirsen, 10 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1429	Injection, golodirsen, 10 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1437	Injection, ferric derisomaltose, 10 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1438	Injection, etanercept, 25 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1439	Injection, ferric carboxymaltose, 1mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1440	Fecal microbiota, live - jslm, 1 ml	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1458	Injection, galsulfase, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1595	Injection, glatiramer acetate, 20 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1602	Injection, golimumab, 1 mg, for intravenous use	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1628	Injection, guselkumab, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1632	Injection, brexanolone, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1743	Injection, idursulfase, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1744	Injection, icatibant, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1745	Injection, infliximab, excludes biosimilar, 10 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1746	Injection, ibalizumab-uiyk, 10 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1747	Injection, spesolimab-sbzo, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1748	infliximab-dyyb	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1786	Injection, imiglucerase, 10 units	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1809	Injection, fosdenopterin, 0.1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1823	Injection, inebilizumab-cdon, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1826	Injection, interferon beta-1a, 30 mcg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1830	Interferon Beta-1b / .25 Mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1931	Injection, laronidase, 0.1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1950	Injection, leuprolide acetate (for depot suspension), per 3.75 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1951	Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 m	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1954	Injection, leuprolide acetate for depot suspension (lutrate depot), 7.5 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J1961	Injection, lenacapavir, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2170	Injection, mecasermin, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2182	Injection, mepolizumab, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2267	Injection, mirikizumab-mrkz, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2278	Injection, ziconotide, 1 mcg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2323	Imjection, natalizumab, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2326	Injection, nusinersen, 0.1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2327	Injection, risankizumab-rzaa, intravenous, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2329	Injection, ublituximab-xiiy, 1mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2350	Injection, ocrelizumab, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2351	Injection, ocrelizumab, 1 mg and hyaluronidase- ocsq	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2356	Injection, tezepelumab-ekko, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2357	Injection, omalizumab, 5 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2361	Injection, depemokimab-ulaa, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2502	Injection, pasireotide long acting, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2507	Injection, pegloticase, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2508	Injection, pegunigalsidase alfa-iwxj, 1 mg	Standard Local Prior Authorization Code List, Pg 121 Original policy
J2777	Injection, faricimab-svoa, 0.1 mg	Standard Local Prior Authorization Code List, Pg 122 Original policy
J2778	Injection, ranibizumab, 0.1 mg	Standard Local Prior Authorization Code List, Pg 122 Original policy
J2781	Injection, pegcetacoplan, intravitreal, 1 mg	Standard Local Prior Authorization Code List, Pg 122 Original policy
J2782	Injection, avacincaptad pegol, 0.1 mg	Standard Local Prior Authorization Code List, Pg 122 Original policy
J2786	Injection, reslizumab, 1 mg	Standard Local Prior Authorization Code List, Pg 122 Original policy

Sources

Standard Local Prior Authorization Code List