Blue Shield of California Promise Health Plan prior authorization, page 27
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 |
|---|---|---|
| J3247 | secukinumab IV (Cosentyx IV) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3262 | Tocilizumab (Actemra) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3263 | toripalimab-tpzi (Loqtorzi) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3285 | Treprostinil (Remodulin) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3316 | Triptorelin (Triptodur) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3357 | Ustekinumab (Stelara SC) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3358 | Ustekinumab (Stelara IV) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3380 | Vedolizumab (Entyvio) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3385 | Velaglucerase alfa (VPRIV) | Medi-Cal Prior Authorization List, Pg 48 Original policy |
| J3386 | etuvetidigene autotemcel (Waskyra) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3387 | Rigid Lumbar Orthosis | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3389 | Ladies Footwear, Inlay | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3391 | atidarsagene autotemcel (Lenmeldy) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3393 | betibeglogene autotemcel (Zynteglo) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3397 | Vestronidase alfa-vjbk (Mepsevii) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3398 | Voretigene neparvovec-rzyl (Luxturna) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3399 | Onasemnogene abeparvovec-xioi (Zolgensma) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3401 | Beremagene geperpavec-svdt (Vyjuvek) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3402 | remestemcel-L-rknd (Ryoncil) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3403 | Revakinagene taroretcel-lwey (Encelto) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3404 | zopapogene imadenovec-drba (Papzimeos) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3405 | onasemnogene abeparvovec-brve (Itvisma) | Medi-Cal Prior Authorization List, Pg 49 Original policy |
| J3490 | Interferon gamma-1b (Actimmune) | Medi-Cal Prior Authorization List, Pg 50 Original policy |
| C9399 | Interferon gamma-1b (Actimmune) | Medi-Cal Prior Authorization List, Pg 50 Original policy |
| J3590 | Peanut (Arachis hypogaea) allergen powder-dnfp (Palforzia) | Medi-Cal Prior Authorization List, Pg 53 Original policy |
| J9999 | Amtagvi (lifileucel) | Medi-Cal Prior Authorization List, Pg 55 Original policy |
| J9021 | Asparaginase erwinia chrysanthemi [recombinant]-rywn (Rylaze) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9022 | Atezolizumab (Tecentriq) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9023 | Avelumab (Bavencio) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9024 | atezolizumab and hyaluronidase-tqjs (Tecentriq Hybreza) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9026 | tarlatamab-dlle (Imdelltra) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9028 | nogapendekin alfa inbakicept-pmln (Anktiva) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9029 | Nadofaragene firadenovec-vncg (Adstiladrin®) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9032 | Belinostat (Beleodaq) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9033 | Bendamustine(Treanda) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9034 | Bendamustine (Bendeka) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9035 | Bevacizumab (Avastin) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9036 | Bendamustine (Belrapzo) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9038 | axatilimab-csfr (Niktimvo) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9039 | Blinatumomab (Blincyto) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9041 | Bortezomib (Velcade) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9042 | Brentuximab Vedotin (Adcetris) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9043 | Cabazitaxel (Jevtana) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9046 | bortezomib (dr. reddy's) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9047 | Carfilzomib (Kyprolis) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9048 | bortezomib (fresenius kabi) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9049 | bortezomib (hospira) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9051 | Bortezomib (maia) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9053 | belantamab mafodotin-blmf (Blenrep) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9054 | bortezomib (boruzu) | Medi-Cal Prior Authorization List, Pg 56 Original policy |