Blue Shield of California Promise Health Plan prior authorization, page 28
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 |
|---|---|---|
| J9055 | Cetuximab (Erbitux) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9056 | Bendamustine | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9057 | Copanlisib (Aliqopa) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9061 | Amivantamab-vmjw (Rybrevant) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9062 | amivantamab 5 mg and hyaluronidase-lpuj (Rybrevant Faspro) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9063 | Mirvetuximab Soravtansine-gynx (Elahere™) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9064 | Cabazitaxel (sandoz) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9118 | Calaspargase pegol-mknl (Asparlas) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9119 | Cemiplimabrwlc (Libtayo) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9144 | Daratumumab and hyaluronidase-fihj ( Darzalex Faspro) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9145 | Daratumumab (Darzalex) | Medi-Cal Prior Authorization List, Pg 56 Original policy |
| J9153 | Daunorubicin and cytarabine liposome (Vyxeos) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9155 | Degarelix | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9161 | denileukin diftitox-cxdl (Lymphir) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9173 | Durvalumab (Imfinzi) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9176 | Elotuzumab (Empliciti) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9177 | Enfortumab vedotin-ejfv (Padcev) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9179 | Eribulin (Halaven) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9203 | Gemtuzumab ozogamicin (Mylotarg) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9204 | Mogamulizumab-kpkc (Poteligeo) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9205 | Irinotecan liposome (Onivyde) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9207 | Ixabepilone (Ixempra) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9210 | Emapalumab-lzsg (Gamifant) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9216 | interferon, gamma-1b (Actimmune) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9223 | Lurbinectedin (Zepzelca) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9226 | Histrelin Implant (Supprelin LA) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9227 | Isatuximab-irfc (Sarclisa) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9228 | Ipilimumab (Yervoy) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9229 | Inotuzumab ozogamicin (Besponsa) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9248 | melphalan (Hepzato) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9256 | Static / Dynamic Ankle Foot Orthosis | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9262 | Omacetaxine (Synribo) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9266 | pegaspargase (Oncaspar) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9269 | tagraxofusp-erzs (Elzonris) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9271 | Pembrolizumab (Keytruda) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9272 | dostarlimab-gxly (Jemperli) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9273 | Tisotumab vedotin-tftv (Tivdak) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9274 | Tebentafusp-tebn (Kimmtrak) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9275 | cosibelimab-ipdl (Unloxcyt) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9276 | zanidatamab-hrii (Ziihera) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9277 | pembrolizumab and berahyaluronidase alfa-pmph (Keytruda Qlex) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9282 | Mitomycin (Zusduri) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9286 | glofitamab-gxbm (Columvi) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9289 | nivolumab and hyaluronidase-nvhy (Opdivo Qvantig) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9292 | pemetrexed (avyxa) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9294 | pemetrexed (hospira) | Medi-Cal Prior Authorization List, Pg 57 Original policy |
| J9295 | Necitumumab (Portrazza) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9296 | pemetrexed (accord) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9297 | pemetrexed (sandoz) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9298 | Nivolumab and relatlimab-rmbw (Opdualag) | Medi-Cal Prior Authorization List, Pg 58 Original policy |