Blue Shield of California Promise Health Plan prior authorization, page 30
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 |
|---|---|---|
| Q2054 | Lisocabtagene maraleucel (Breyanzi) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q2055 | Idecabtagene vicleucel (Abecma) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q2056 | Ciltacabtagene autoleucel (Carvykti) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q2057 | afamitresgene autoleucel (Tecelra) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q2058 | obecabtagene autoleucel (Aucatzyl) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q3027 | Interferon beta 1A (Avonex) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q3028 | interferon beta 1a (Rebif) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q5098 | ustekinumab-srlf (imuldosa) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q5099 | ustekinumab-stba (steqeyma) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q5100 | ustekinumab-kfce (yesintek) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q5101 | Filgrastim-sndz (Zarxio) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q5103 | Infliximab-dyyb (Inflectra) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q5104 | Infliximab-abda (Renflexis) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q5106 | Epoetin alfa-epbx, non-ESRD (Retacrit) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q5107 | Bevacizumab-awwb (Mvasi) | Medi-Cal Prior Authorization List, Pg 59 Original policy |
| Q5108 | Pegfilgrastim-jmdb (Fulphila) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5110 | Filgrastim-aafi (Nivestym) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5111 | Pegfilgrastim-cbqv (Udenyca) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5112 | Trastuzumab-dttb (Ontruzant) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5113 | Trastuzumab-pkrb (Herzuma) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5114 | Trastuzumab-dkst (Ogivri) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5115 | Rituximab-abbs (Truxima) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5116 | Trastuzumab-qyyp (Trazimera) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5117 | Trastuzumab-anns (Kanjinti) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5118 | Bevacizumab-bvzr (Zirabev) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5119 | Rituximab-pvvr (Ruxience) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5120 | Pegfilgrastim-bmez (Ziextenzo) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5121 | Infliximab-axxq (Avsola) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5122 | Pegfilgrastim-apgf (Nyvepria) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5123 | Rituximab-arrx (Riabni) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5124 | Ranibizumab-numa (Byooviz) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5125 | Filgrastim-ayow (Releuko) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5126 | Bevacizumab-maly (Alymsys) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5127 | Pegfilgrastim-fpgk (Stimufend) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5128 | Ranibizumab-egrn (Cimerli) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5129 | bevacizumab-adcd (Vegzelma) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5130 | Pegfilgrastim-pbbk (Fylnetra) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5133 | tocilizumab (Tofidence) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5134 | natalizumab-sztn (Tyruko) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5135 | tocilizumab-aazg (Tyenne) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5136 | denosumab-bbdz (Jubbonti/Wyost) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5137 | ustekinumab-auub SC (Wezlana SC) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5138 | ustekinumab-auub IV (Wezlana IV) | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5140 | adalimumab-fkjp, biosimilar | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5141 | adalimumab-aaty, biosimilar | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5142 | adalimumab-ryvk biosimilar | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5143 | adalimumab-adbm, biosimilar | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5144 | adalimumab-aacf (idacio), biosimilar | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5145 | adalimumab-afzb (abrilada), biosimilar | Medi-Cal Prior Authorization List, Pg 60 Original policy |
| Q5146 | trastuzumab-strf (hercessi) | Medi-Cal Prior Authorization List, Pg 60 Original policy |