Blue Shield of California Promise Health Plan prior authorization, page 24
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 |
|---|---|---|
| J0490 | Belimumab (Benlysta), intravenous | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0491 | Anifrolumab-fnia (Saphnelo) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0517 | Benralizumab (Fasenra) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0567 | Cerliponase alfa (Brineura) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0584 | Burosumab-twza (Crysvita) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0585 | OnabotulinumtoxinA (Botox) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0586 | AbobotulinumtoxinA (Dysport) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0587 | RimabotulinumtoxinB (Myobloc) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0588 | IncobotulinumtoxinA (Xeomin) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0589 | daxibotulinumtoxina-lanm (Daxxify) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0593 | Lanadelumab-flyo (Takhzyro) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0596 | C1 Esterase Inhibitor, recombinant (Ruconest) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0597 | C1 Esterase Inhibitor (Berinert) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0598 | C1 Esterase Inhibitor (Cinryze) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0599 | C1 Esterase Inhibitor (Haegarda) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0638 | Canakinumab (Ilaris) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0642 | Levoleucovorin (Khapzory) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0717 | Certolizumab (Cimzia) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0775 | Collagenase clostridium histolyticum (Xiaflex) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0791 | Crizanlizumab-tmca (Adakveo) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0801 | Repository corticotropin (Acthar) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0802 | Repository corticotropin (Cortrophin) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0850 | Intravenous immune globulin (Cytogam) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0870 | imetelstat (Rytelo) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0879 | Difelikefalin (Korsuva) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0881 | Darbepoetin alfa, Non-ESRD (Aranesp) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0885 | Epoetin alfa, non-ESRD (Epogen, Procrit) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0888 | methoxy polyethylene glycolepoetin beta, non-ESRD (Mircera) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0896 | Luspatercept-aamt (Reblozyl) | Medi-Cal Prior Authorization List, Pg 44 Original policy |
| J0897 | Denosumab (Prolia) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1072 | testosterone cypionate (Azmiro) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1073 | Multi-ligament Support Ankle Foot Orthosis | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1202 | miglustat (Opfolda) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1203 | cipaglucosidase alfa-atga (Pombiliti) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1289 | narsoplimab-wuug (Yartemlea) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1290 | Ecallantide (Kalbitor) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1299 | eculizumab (Soliris) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1301 | Edaravone (Radicava) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1302 | Sutimlimab-jome (Enjaymo ) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1303 | Ravulizumab-cwvz (Ultomiris) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1304 | tofersen (Qalsody) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1305 | Evinacumab-dgnb (Evkeeza) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1306 | Inclisiran (Leqvio) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1307 | crovalimab-akkz (Piasky) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1322 | Elosulfase alfa (Vimizim) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1323 | elranatamab-bcmm (Elrexfio) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1325 | Epoprostenol (Flolan Veletri ) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1326 | zolbetuximab-clzb (Vyloy) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1411 | etranacogene dezaparvovec-drlb (Hemgenix) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1412 | valoctocogene roxaparvovec-rvox (Roctavian) | Medi-Cal Prior Authorization List, Pg 45 Original policy |