Blue Shield of California Promise Health Plan prior authorization, page 25
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 |
|---|---|---|
| J1413 | delandistrogene moxeparvovec-rokl (Elevidys) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1426 | casimersen (Amondys 45) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1427 | Viltolarsen (Viltepso) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1428 | Eteplirsen (Exondys 51) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1429 | Golodirsen (Vyondys 53) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1437 | Monoferric (ferric derisomaltose) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1438 | Etanercept (Enbrel ) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1439 | Injectafer (ferric carboxymaltose, IV) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1440 | Fecal Microbiota, Live - jslm (Rebyota™) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1442 | Filgrastim (Neupogen) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1447 | Tbo-filgrastim (Granix) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1448 | Trilaciclib (Cosela) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1449 | Eflapegrastim-xnst (Rolvedon) | Medi-Cal Prior Authorization List, Pg 45 Original policy |
| J1458 | Galsulfase (Naglazyme) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1459 | Intravenous immune globulin (Privigen) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1551 | Subcutaneous immune globulin (Cutaquig) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1552 | immune globulin (alyglo) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1553 | immune globulin (yimmugo) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1554 | Intravenous immune globulin (Asceniv) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1555 | Subcutaneous immune globulin (Cuvitru) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1556 | Immune globulin (Bivigam) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1557 | Intravenous immune globulin (Gammaplex) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1558 | Subcutaneous immune globulin (Xembify) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1559 | Subcutaneous immune globulin (Hizentra) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1561 | Intravenous immune globulin (Gammaked) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1568 | Intravenous immune globulin (Octagam) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1569 | Intravenous immune globulin (Gammagard liquid) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1572 | Intravenous immune globulin (Flebogamma Dif) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1575 | Subcutaneous immune globulin (HyQvia) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1576 | Immune Globulin (Panzyga) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1577 | immune globulin (Qivigy) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1595 | Multiple Sclerosis Drug Therapy Glatiramer (Copaxone ) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1599 | Immune globulin, intravenous, non-lyophilized, not otherwise specified | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1602 | Golimumab (Simponi Aria) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1628 | Guselkumab (Tremfya) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1743 | Idursulfase (Elaprase) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1744 | Icatibant (Firazyr) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1745 | Infliximab (remicade) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1747 | Spesolimab-sbzo (Spevigo) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1748 | infliximab-dyyb (Zymfentra) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1750 | INFeD (iron dextran) | Medi-Cal Prior Authorization List, Pg 46 Original policy |
| J1786 | Imiglucerase (Cerezyme) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1809 | fosdenopterin (Nulibry) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1823 | Inebilizumab-cdon (Uplizna) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1826 | Interferon beta 1A (Avonex) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1830 | interferon beta-1b (Betaseron) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1833 | Isavuconazonium (Cresemba ) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1837 | Electric Suction Pump, Portable or Stationary | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1930 | Lanreotide (Somatuline) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1931 | Laronidase (Aldurazyme) | Medi-Cal Prior Authorization List, Pg 47 Original policy |