Talk to Us

Blue Cross and Blue Shield of Montana prior authorization, page 33

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
CodeDescriptionSource
G2082Spravato (esketamine, nasal BCBSMT spray) > 56 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
G2083Spravato (esketamine, nasal BCBSMT spray) > 56 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0013Spravato (esketamine, nasal BCBSMT spray)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0129Injection Abatacept 10 Mg BCBSMT (Code May Be Used For Medicare When Drug Administered Under The Direct Supervision Of A Physician Not For Use When Drug Is Self Administered)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0174Injection, lecanemab-irmb, 1 BCBSMT mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0175Injection, donanemab-azbt, 2 BCBSMT mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0180Injection Agalsidase Beta 1 BCBSMT Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0202Injection Alemtuzumab 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0218Injection, olipudase alfa-rpcp, BCBSMT 1 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0219Injection Avalglucosidase BCBSMT Alfa-Ngpt 4 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0221Injection Alglucosidase Alfa BCBSMT (Lumizyme) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0222Injection Patisiran 0.1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0223Injection, givosiran, 0.5 mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0224Injection, lumasiran, 0.5 mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 3 Original policy
J0225Injection, vutrisiran, 1 mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0485Injection Belatacept 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0490Injection Belimumab 10 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0491Injection Anifrolumab-Fnia 1 BCBSMT Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0517Injection Benralizumab 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0567Injection Cerliponase Alfa 1 BCBSMT Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0584Injection Burosumab-Twza 1 BCBSMT Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0585Injection BCBSMT Onabotulinumtoxina 1 Unit2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0586Injection Abobotulinumtoxina BCBSMT 5 Units2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0587Injection BCBSMT Rimabotulinumtoxinb 100 Units2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0588Injection Incobotulinumtoxin BCBSMT A 1 Unit2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0589Injection, BCBSMT Daxibotulinumtoxina-Lanm, 1 Unit2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0598Injection C-1 Esterase BCBSMT Inhibitor (Human) Cinryze 10 Units2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0638Injection Canakinumab 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0642Injection Levoleucovorin Carelon (Khapzory) 0.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 4 Original policy
J0717Injection Certolizumab Pegol BCBSMT 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)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0741Injection Cabotegravir And BCBSMT Rilpivirine 2Mg/3Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0775Injection Collagenase BCBSMT Clostridium Histolyticum 0.01 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0791Injection Crizanlizumab- BCBSMT Tmca 5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0870Imetelstat (Rytelo)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0881Injection Darbepoetin Alfa 1 Carelon or Microgram (Non-Esrd Use) BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0882Injection Darbepoetin Alfa 1 Carelon Microgram (For Esrd On Dialysis)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0885Injection Epoetin Alfa (For Carelon or Non-Esrd Use) 1000 Units BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0888Injection, epoetin beta, 1 BCBSMT microgram, (for non esrd use)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0896Injection Luspatercept-Aamt Carelon 0.25 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J0897Injection Denosumab 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 5 Original policy
J1203Injection, Cipaglucosidase BCBSMT Alfa-Atga, 5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1289Yartemlea (narsoplimab- BCBSMT wuug)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1290Injection Ecallantide 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1299Injection, eculizumab, 2 mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1301Injection Edaravone 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1302Injection Sutimlimab-Jome BCBSMT 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1303Injection Ravulizumab-Cwvz BCBSMT 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1304Injection, Tofersen, 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1305Injection Evinacumab-Dgnb BCBSMT 5Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1306Injection Inclisiran 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

This website uses cookies to ensure you get the best experience on our website. Learn more