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Blue Cross and Blue Shield of Montana prior authorization, page 38

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
Q2043Sipuleucel-T Minimum Of 50 Carelon Million Autologous Cd54+ Cells Activated With Pap-Gm- Csf Including Leukapheresis And All Other Preparatory Procedures Per Infusion2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 24 Original policy
Q2050Injection Doxorubicin Carelon Hydrochloride Liposomal Not Otherwise Specified 10Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 24 Original policy
Q2053Brexucabtagene Autoleucel BCBSMT Up 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
Q2054Lisocabtagene Maraleucel Up BCBSMT To 110 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 25 Original policy
Q2055Idecabtagene Vicleucel Up To BCBSMT 460 Million Autologous B-Cell Maturation Antigen (Bcma) Directed Car-Positive T Cells Including Leukapheresis And Dose Preparation Procedures Per Therapeutic Dose2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 25 Original policy
Q2056Ciltacabtagene Autoleucel BCBSMT Up To 100 Million Autologous B-Cell Maturation Antigen (Bcma) Directed Car-Positive T Cells Including Leukapheresis And Dose Preparation Procedures Per Therapeutic Dose2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 25 Original policy
Q2057Afamitresgene autoleucel, BCBSMT including leukapheresis and dose preparation procedures, per therapeutic dose2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 25 Original policy
Q2058Obecabtagene autoleucel, 10 BCBSMT up to 400 million cd19 car- positive viable t cells, including leukapheresis and dose preparation procedures, per infusion2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q4081Injection Epoetin Alfa 100 Carelon Units (For Esrd On Dialysis)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5098Injection, ustekinumab-srlf BCBSMT (imuldosa), biosimilar, 1 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5099Injection, ustekinumab-stba BCBSMT (steqeyma), biosimilar, 1 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5100Injection, ustekinumab-kfce BCBSMT (yesintek), biosimilar, 1 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5101Injection Filgrastim-Sndz Carelon Biosimilar (Zarxio) 1 Microgram2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5103Injection Infliximab-Dyyb BCBSMT Biosimilar (Inflectra) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5104Injection Infliximab-Abda BCBSMT Biosimilar (Renflexis) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5105Injection Epoetin Alfa-Epbx Carelon Biosimilar (Retacrit) (For Esrd On Dialysis) 100 Units2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5106Injection Epoetin Alfa-Epbx Carelon or Biosimilar (Retacrit) (For Non-BCBSMT Esrd Use) 1000 Units2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5107Injection Bevacizumab-Awwb Carelon Biosimilar (Mvasi) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 26 Original policy
Q5108Injection Pegfilgrastim-Jmdb Carelon (Fulphila) Biosimilar 0.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5109Injection Infliximab-Qbtx BCBSMT Biosimilar (Ixifi) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5110Injection Filgrastim-Aafi Carelon Biosimilar (Nivestym) 1 Microgram2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5111Injection Pegfilgrastim-Cbqv Carelon (Udenyca) Biosimilar 0.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5112Injection Trastuzumab-Dttb Carelon Biosimilar (Ontruzant) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5113Injection Trastuzumab-Pkrb Carelon Biosimilar (Herzuma) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5114Injection Trastuzumab-Dkst Carelon Biosimilar (Ogivri) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5115Injection Rituximab-Abbs Carelon or Biosimilar (Truxima) 10 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5116Injection Trastuzumab-Qyyp Carelon Biosimilar (Trazimera) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5117Injection Trastuzumab-Anns Carelon Biosimilar (Kanjinti) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5118Injection Bevacizumab-Bvzr Carelon Biosimilar (Zirabev) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 27 Original policy
Q5119Injection Rituximab-Pvvr Carelon or Biosimilar (Ruxience) 10 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5120Injection Pegfilgrastim-Bmez Carelon (Ziextenzo) Biosimilar 0.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5121Injection Infliximab-Axxq BCBSMT Biosimilar (Avsola) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5122Injection Pegfilgrastim-Apgf Carelon (Nyvepria) Biosimilar 0.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5123Injection Rituximab-Arrx Carelon or Biosimilar (Riabni) 10 Mg BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5125Injection Filgrastim-Ayow Carelon Biosimilar (Releuko) 1 Microgram2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5126Injection Bevacizumab-Maly Carelon Biosimilar (Alymsys) 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5127Injection Pegfilgrastim-Fpgk Carelon (Stimufend) Biosimilar 0.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5129Injection Bevacizumab-Adcd Carelon (Vegzelma) Biosimilar 10 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5130Injection Pegfilgrastim-Pbbk Carelon (Fylnetra) Biosimilar 0.5 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5133Injection, Tocilizumab-Bavi BCBSMT (Tofidence), Biosimilar, 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5134Injection, Natalizumab-Sztn BCBSMT (Tyruko), Biosimilar, 1 Mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 28 Original policy
Q5135Injection, tocilizumab-aazg BCBSMT (tyenne), biosimilar, 1 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 29 Original policy
Q5136Injection, denosumab-bbdz Carelon (jubbonti/wyost), biosimilar, 1 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 29 Original policy
Q5138ustekinumab-auub BCBSMT2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 29 Original policy
Q5146Trastuzumab-strf (Hercessi)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 29 Original policy
Q5148Nypozi (filgrastim-txid)2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 29 Original policy
Q5151Injection, eculizumab-aagh BCBSMT (epysqli), biosimilar, 2 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 29 Original policy
Q5152Injection, eculizumab-aeeb BCBSMT (bkemv), biosimilar, 2 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 29 Original policy
Q5154Injection, omalizumab-igec BCBSMT (omlyclo), biosimilar, 5 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 29 Original policy
Q5156Injection, tocilizumab-anoh BCBSMT (avtozma), biosimilar, 1 mg2026 Specialty Drugs and Infusion Site of Care Prior Authorization Code List, Pg 29 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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