Anthem Blue Cross Blue Shield of Georgia prior authorization, page 53
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 |
|---|---|---|
| J7203 | Injection Factor IX, (antihemophilic factor, recombinant), glycoPEGylated, (Rebinyn), 1 IU | Standard Local Prior Authorization Code List, Pg 122 Original policy |
| J7204 | Injection, Factor VIII, antihemophilic factor (recombinant), (Esperoct), glycopegylated-exei, per IU | Standard Local Prior Authorization Code List, Pg 122 Original policy |
| J7205 | Injection, Factor VIII Fc fusion protein (recombinant), per IU | Standard Local Prior Authorization Code List, Pg 122 Original policy |
| J7207 | Injection, Factor VIII, (antihemophilic factor, recombinant), PEGylated, 1 IU | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7208 | Injection, Factor VIII, (antihemophilic factor, recombinant), PEGylated-aucl, (Jivi), 1 IU | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7209 | Injection, Factor VIII, (antihemophilic factor, recombinant), (Nuwiq), 1 IU | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7210 | Injection, Factor VIII, (antihemophilic factor, recombinant), (Afstyla), 1 IU | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7211 | Injection, Factor VIII, (antihemophilic factor, recombinant), (Kovaltry), 1 IU | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7212 | Factor VIIa (antihemophilic factor, recombinant)- jncw (Sevenfact), 1 mcg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7213 | Injection, coagulation factor ix (recombinant), ixinity, 1 i.u. | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7214 | Injection, Factor VIII/von Willebrand factor complex, recombinant (Altuviiio), per Factor VIII IU | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7311 | Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7312 | Injection, dexamethasone, intravitreal implant, 0.1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7313 | Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7314 | Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7340 | Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7351 | Injection, bimatoprost, intracameral implant, 1 microgram | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7352 | Afamelanotide implant, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7353 | Anacaulase-bcdb, 8.8% gel, 1 gm | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7354 | Cantharidin for topical administration, 0.7%, single unit dose applicator (3.2 mg) | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7355 | Injection, travoprost, intracameral implant, 1 mcg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7356 | Injection, foscarbidopa 0.25 mg/foslevodopa 5 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7686 | Treprostinil, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, 1.74 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J7999 | Compounded drug, not otherwise classified | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9038 | Injection, axatilimab-csfr, 0.1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9202 | Goserelin acetate implant, per 3.6 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9210 | Injection, emapalumab-lzsg, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9217 | Leuprolide acetate (for depot suspension), 7.5 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9226 | Histrelin implant (supprelin LA), 50 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9256 | Injection, nipocalimab-aahu, 3 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9312 | Injection, rituximab, 10 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9332 | Injection, efgartigimod alfa-fcab, 2mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9333 | Injection, rozanolixizumab-noli, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9334 | Injection, efgartigimod alfa, 2 mg and hyaluronidase- qvfc | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9376 | Injection, pozelimab-bbfg, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| J9381 | Injection, teplizumab-mzwv, 5 mcg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q3027 | Injection, interferon beta-1a, 1 mcg for intramuscular use | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q3028 | Injection, interferon beta-1a, 1 mcg for subcutaneous use | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5098 | Injection, ustekinumab-srlf (imuldosa), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5099 | Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5100 | Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5103 | Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5104 | Injection, infliximab-abda, biosimilar, (renflexis), 10 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5121 | Injection, infliximab-axxq, biosimilar, (AVSOLA), 10 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5123 | Injection, rituximab-arrx, biosimilar, (riabni), 10 m | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5124 | Injection, ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5128 | Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5134 | Injection, natalizumab-sztn (Tyruko), biosimilar, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5137 | Injection, ustekinumab-auub (Wezlana), biosimilar, SC, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |
| Q5138 | Injection, ustekinumab-auub (Wezlana), biosimilar, IV, 1 mg | Standard Local Prior Authorization Code List, Pg 123 Original policy |