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Blue Cross and Blue Shield of Montana prior authorization, page 37

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
J9275Unloxcyt (cosibelimab-ipdl)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 19 Original policy
J9276Ziihera (zanidatamab-hrii)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 19 Original policy
J9277Keytruda Qlex Carelon (pembrolizumab and berahyaluronidase alfa- pmph)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9281Mitomycin Pyelocalyceal Carelon Instillation 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9282mitomycin2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9286Injection Glofitamab-Gxbm Carelon 2.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9289Opdivo Qvantig (nivolumab Carelon hyaluronidase-nvhy)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9295Injection Necitumumab 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9298Injection Nivolumab And Carelon Relatlimab-Rmbw 3 Mg/1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9299Injection Nivolumab 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9301Injection Obinutuzumab 10 Carelon or Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9302Injection Ofatumumab 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9303Injection Panitumumab 10 Carelon Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9306Injection Pertuzumab 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9308Injection Ramucirumab 5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9309Injection Polatuzumab Carelon Vedotin-Piiq 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 20 Original policy
J9311Injection Rituximab 10 Mg Carelon And Hyaluronidase2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9312Injection Rituximab 10 Mg Carelon or BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9316Injection Pertuzumab Carelon Trastuzumab And Hyaluronidase-Zzxf Per 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9317Injection Sacituzumab Carelon Govitecan-Hziy 2.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9321Injection Epcoritamab-Bysp Carelon 0.16 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9325Injection Talimogene Carelon Laherparepvec Per 1 Million Plaque Forming Units2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9326telisotuzumab vedotin-tllv2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9329Injection, tislelizumab-jsgr, Carelon 1mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9331Injection Sirolimus Protein- Carelon Bound Particles 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9332Injection Efgartigimod Alfa- BCBSMT Fcab 2Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9333Injection, rozanolixizumab- BCBSMT noli, 1 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9334Injection, efgartigimod alfa, 2 BCBSMT mg and hyaluronidase-qvfc2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9345Injection Retifanlimab-Dlwr 1 Carelon Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9347Injection Tremelimumab-Actl Carelon 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 21 Original policy
J9348Injection Naxitamab-Gqgk 1 Carelon Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9349Injection Tafasitamab-Cxix 2 Carelon Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9350Injection Mosunetuzumab- Carelon Axgb 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9352Injection Trabectedin 0.1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9353Injection Margetuximab- Carelon Cmkb 5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9354Injection Ado-Trastuzumab Carelon Emtansine 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9355Injection Trastuzumab Carelon Excludes Biosimilar 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9356Injection Trastuzumab 10 Mg Carelon And Hyaluronidase-Oysk2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9358Injection Fam-Trastuzumab Carelon Deruxtecan-Nxki 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9359Injection Loncastuximab Carelon Tesirine-Lpyl 0.075 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9361Ryzneuta (efbemalenograstim Carelon alfa-vuxw)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9362Trabectedin2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9376Injection, pozelimab-bbfg, 1 BCBSMT mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9380Injection Teclistamab-Cqyv Carelon 0.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9381Tzield (teplizumab-mzwv) BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9382Bizengri (zenocutuzumab- Carelon zbco)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9601Lynozyfic (linvoseltamab- Carelon gcpt)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 22 Original policy
J9999Not Otherwise Classified Carelon Antineoplastic Drugs2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 23 Original policy
Q2041Axicabtagene Ciloleucel Up BCBSMT To 200 Million Autologous Anti- Cd19 Car Positive Viable T Cells Including Leukapheresis And Dose Preparation Procedures Per Therapeutic Dose2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 24 Original policy
Q2042Tisagenlecleucel Up To 600 BCBSMT Million Car-Positive Viable T Cells Including Leukapheresis And Dose Preparation Procedures Per Therapeutic Dose2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 24 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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