Blue Shield of California Promise Health Plan prior authorization, page 26
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 |
|---|---|---|
| J1932 | Lanreotide (cipla) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1951 | Leuprolide acetate (Fensolvi) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J1952 | Leuprolide mesylate (Camcevi) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2170 | Mecasermin (Increlex ) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2182 | Mepolizumab (Nucala) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2212 | Methylnaltrexone (Relistor ) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2267 | mirikizumab-mrkz (Omvoh) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2277 | motixafortide acetate (Aphexda) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2278 | Ziconotide (Prialt ) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2323 | Natalizumab (Tysabri) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2326 | Nusinersen (Spinraza) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2327 | Risankizumab-rzaa (Skyrizi), intravenous | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2329 | Ublituximab-xiiy (Briumvi™) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2350 | Ocrelizumab (Ocrevus) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2351 | ocrelizumab and hyaluronidase-ocsq (Ocrevus Zunovo) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2353 | Octreotide (Sandostatin LAR) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2354 | Octreotide (Sandostatin) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2356 | Tezepelumab-ekko (Tezspire) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2357 | Omalizumab (Xolair) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2361 | depemokimab-ulaa (Exdensur) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2425 | Palifermin (Kepivance) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2502 | Pasireotide (Signifor LAR ) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2506 | Pegfilgrastim (Neulasta) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2507 | Pegloticase (Krystexxa) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2508 | pegunigalsidase alfa-iwxj (Elfabrio) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2547 | Peramivir (Rapivab) | Medi-Cal Prior Authorization List, Pg 47 Original policy |
| J2562 | Plerixafor (Mozobil) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2724 | Protein C concentrate (Ceprotin) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2777 | Faricimab-svoa (Vabysmo) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2778 | Ranibizumab (Lucentis) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2779 | Ranibizumab-sustained release intravitreal implant (Susvimo) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2781 | Pegcetacoplan (Syfovre) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2782 | avacincaptad pegol (Izervay) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2786 | Reslizumab (Cinqair) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2793 | Rilonacept (Arcalyst) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2802 | romiplostim (Nplate) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2820 | Sargramostim (GM-CSF, Leukine) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2840 | Sebelipase alfa (Kanuma) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2860 | Siltuximab (Sylvant) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J2998 | Plasminogen, human-tvmh (Ryplazim) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3030 | Sumatriptan Injection (Imitrex) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3031 | Fremanezumab-vfrm (Ajovy) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3032 | eptinezumab-jjmr (Vyepti) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3055 | talquetamab-tgvs (Talvey) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3060 | Taliglucerase (Elelyso) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3110 | Teriparatide (Forteo ) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3111 | Romosozumab-aqqg (Evenity) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3145 | Testosterone undecanoate (Aveed) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3241 | teprotumumab-trbw (Tepezza) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3245 | Tildrakizumab-asmn (Ilumya) | Medi-Cal Prior Authorization List, Pg 48 Original policy |