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Blue Cross and Blue Shield of Montana 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

Prior authorization codes
CodeDescriptionSource
J1307Injection, crovalimab-akkz, 10 BCBSMT mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1322Injection Elosulfase Alfa 1Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1323Injection Elranatamab-Bcmm Carelon 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1326Vyloy (zolbetuximab-clzb)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1411Injection Etranacogene BCBSMT Dezaparvovec-Drlb Per Therapeutic Dose2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1412Injection Valoctocogene BCBSMT Roxaparvovec-Rvox Per Ml Containing Nominal 2 X 10^13 Vector Genomes2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 6 Original policy
J1413Injection Delandistrogene BCBSMT Moxeparvovec-Rokl Per Therapeutic Dose2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1426Injection, Casimersen, 10 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1427Injection, Viltolarsen, 10 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1428Injection Eteplirsen 10 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1429Injection, Golodirsen, 10 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1442Injection Filgrastim (G-Csf) Carelon Excludes Biosimilars 1 Microgram2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1447Injection Tbo-Filgrastim 1 Carelon Microgram2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1448Injection Trilaciclib 1Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1449Injection Eflapegrastim-Xnst Carelon 0.1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1458Injection Galsulfase 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1459Injection Immune Globulin Carelon or (Privigen) Intravenous Non- BCBSMT Lyophilized (E.G. Liquid) 500 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1551Injection Immune Globulin Carelon or (Cutaquig) 100 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1552Injection, immune globulin Carelon or (alyglo), 500 mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 7 Original policy
J1553Immune globulin intravenous, Carelon or human - dira BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 8 Original policy
J1554Injection Immune Globulin Carelon or (Asceniv) 500 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 8 Original policy
J1555Injection Immune Globulin Carelon or (Cuvitru) 100 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 8 Original policy
J1556Injection Immune Globulin Carelon or (Bivigam) 500 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 8 Original policy
J1557Injection Immune Globulin Carelon or (Gammaplex) Intravenous BCBSMT Non-Lyophilized (E.G. Liquid) 500 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 8 Original policy
J1558Injection Immune Globulin Carelon or (Xembify) 100 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 8 Original policy
J1559Injection Immune Globulin Carelon or (Hizentra) 100 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 8 Original policy
J1561Injection Immune Globulin Carelon or (Gamunex-C/Gammaked) BCBSMT Non-Lyophilized (E. G. Liquid) 500 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 8 Original policy
J1562Injection Immune Globulin BCBSMT (Vivaglobin) 100 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 9 Original policy
J1566Injection Immune Globulin Carelon or Intravenous Lyophilized (E. G. BCBSMT Powder) Not Otherwise Specified 500 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 9 Original policy
J1568Injection Immune Globulin Carelon or (Octagam) Intravenous BCBSMT Nonlyophilized (E.G. Liquid) 500 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 9 Original policy
J1569Injection Immune Globulin Carelon or (Gammagard Liquid) Non- BCBSMT Lyophilized (E. G. Liquid) 500 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 9 Original policy
J1572Injection Immune Globulin Carelon or (Flebogamma/Flebogamma BCBSMT Dif) Intravenous Non- Lyophilized (E.G. Liquid) 500 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 9 Original policy
J1575Injection Immune Carelon or Globulin/Hyaluronidase BCBSMT (Hyqvia) 100 Mg Immuneglobulin2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 9 Original policy
J1576Injection Immune Globulin Carelon or (Panzyga) Intravenous Non- BCBSMT Lyophilized (E.G. Liquid) 500 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 9 Original policy
J1577Qivigy (immune globulin Carelon or intravenous, human-kthm) BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 9 Original policy
J1599Injection Immune Globulin Carelon or Intravenous Non-Lyophilized BCBSMT (E.G. Liquid) Not Otherwise Specified 500 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1602Injection Golimumab 1 Mg BCBSMT For Intravenous Use2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1628Injection, guselkumab, 1 mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1743Injection Idursulfase 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1745Injection Infliximab Excludes BCBSMT Biosimilar 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1746Injection Ibalizumab-Uiyk 10 BCBSMT Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1747Injection, Spesolimab-Sbzo, 1 BCBSMT Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1757Avlayah (tividenofusp alfa- BCBSMT eknm)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1786Injection Imiglucerase 10 BCBSMT Units2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1818Loargys (pegzilarginase-nbln) BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1823Injection Inebilizumab-Cdon BCBSMT 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1930Injection Lanreotide 1 Mg Carelon or BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1931Injection Laronidase 0.1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 10 Original policy
J1932Injection, lanreotide, (cipla), 1 Carelon or mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 11 Original policy
J1961Injection Lenacapavir 1 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 11 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.

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