Blue Shield of California Promise Health Plan prior authorization, page 29
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 |
|---|---|---|
| J9299 | Nivolumab (Opdivo) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9301 | Obinutuzumab (Gazyva) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9303 | Panitumumab (Vectibix) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9304 | Pemetrexed (Pemfexy) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9305 | Pemetrexed, not otherwise specified | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9306 | Pertuzumab (Perjeta) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9307 | Pralatrexate (Folotyn) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9308 | Ramucirumab (Cyramza) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9309 | Polatuzumab vedotin-piiq (Polivy) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9311 | Rituximab hyaluronidase (Rituxan Hycela) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9312 | Rituximab (Rituxan) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9314 | pemetrexed (teva) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9316 | Pertuzumab, trastuzumab, and hyaluronidase-zzxf (Phesgo) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9317 | Sacituzumab govitecan-hziy (Trodelvy) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9318 | Romidepsin (Istodax) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9319 | Romidepsin lyophilized | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9321 | epcoritamab-bysp (Epkinly) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9322 | Pemetrexed (Alimta®, Teva, Accord, Hospira, Sandoz and Bluepoint) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9323 | Pemetrexed (Alimta®, Teva, Accord, Hospira, Sandoz and Bluepoint) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9324 | pemetrexed (Pemrydi rtu) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9325 | Talimogene laherparepvec (Imlygic) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9326 | Prefabricated Lumbar-Sacral Orthosis | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9329 | tislelizumab-jsgr (Tevimbra) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9330 | Temsirolius (Torisel) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9331 | Sirolimus protein-bound suspension (Fyarro) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9332 | Efgartigimod alfa-fcab (Vyvgart) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9333 | rozanolixizumab-noli (Rystiggo) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9334 | efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9345 | Retifanlimab (Zynyz) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9347 | tremelimumab-actl (Imjudo) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9348 | Naxitamab-gqgk (Danyelza) | Medi-Cal Prior Authorization List, Pg 58 Original policy |
| J9349 | tafasitamab-cxix (Monjuvi) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9350 | Mosunetuzumab-axgb (Lunsumio™) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9352 | Trabectedin (Yondelis) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9353 | Margetuximab-cmkb (Margenza) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9354 | Ado-trastuzumab (Kadcyla) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9355 | Trastuzumab (Herceptin) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9356 | Trastuzumab and hylaronidase-oysk (Herceptin Hylecta) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9358 | Fam-trastuzumab deruxtecan-nxki (Enhertu) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9359 | Loncastuximab tesirine-lpyl (Zynlonta) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9361 | efbemalenograstim alfa-vuxw (Ryzneuta) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9376 | pozelimab-bbfg (Veopoz) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9380 | Teclistamab-cgyv (TECVAYLI™) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9381 | Teplizumab-mzwv (TZIELD™) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9382 | zenocutuzumab-zbco (Bizengri) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9400 | Ziv-aflibercept (Zaltrap) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| J9601 | linvoseltamab-gcpt (Lynozyfic) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q2041 | Axicabtagene ciloleucel (Yescarta) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q2042 | Tisagenlecleucel (Kymriah) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q2053 | Brexucabtagene autoleucel (Tecartus) | Medi-Cal Prior Authorization List, Pg 59 Original policy |