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Premera Blue Cross of Washington prior authorization, page 34

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

Prior authorization codes
CodeDescriptionSource
J0599Injection, C-1 esterase inhibitor (human), (Haegarda), 10 unitsClinical Review by Code List PBCWA, Pg 699 Original policy
J0614Injection, treosulfan, 50 mgClinical Review by Code List PBCWA, Pg 699 Original policy
J0630Injection, calcitonin salmon, up to 400 unitsClinical Review by Code List PBCWA, Pg 699 Original policy
J0638Injection, canakinumab, 1 mgClinical Review by Code List PBCWA, Pg 699 Original policy
J0717Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)Clinical Review by Code List PBCWA, Pg 699 Original policy
J0725Injection, chorionic gonadotropin, per 1,000 USP unitsClinical Review by Code List PBCWA, Pg 699 Original policy
J0775Injection, collagenase, clostridium histolyticum, 0.01 mgClinical Review by Code List PBCWA, Pg 699 Original policy
J0791Injection, crizanlizumab-tmca, 5 mgClinical Review by Code List PBCWA, Pg 699 Original policy
J0801Injection, corticotropin (acthar gel), up to 40 unitsClinical Review by Code List PBCWA, Pg 699 Original policy
J0802Injection, corticotropin (ani), up to 40 unitsClinical Review by Code List PBCWA, Pg 699 Original policy
J0850Injection, cytomegalovirus immune globulin intravenous (human), per vialClinical Review by Code List PBCWA, Pg 699 Original policy
J0879Injection, difelikefalin, 0.1 microgram, (for ESRD on dialysis) These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 699 Original policy
J0881Injection, darbepoetin alfa, 1 mcg (non- ESRD use)Clinical Review by Code List PBCWA, Pg 700 Original policy
J0882Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)Clinical Review by Code List PBCWA, Pg 700 Original policy
J0885Injection, epoetin alfa, (for non-ESRD use), 1000 unitsClinical Review by Code List PBCWA, Pg 700 Original policy
J0887Injection, epoetin beta, 1 microgram, (for ESRD on dialysis)Clinical Review by Code List PBCWA, Pg 700 Original policy
J0888Injection, epoetin beta, 1 microgram, (for non-ESRD use)Clinical Review by Code List PBCWA, Pg 700 Original policy
J0893Injection, decitabine (Sun Pharma), not therapeutically equivalent to J0894, 1 mgClinical Review by Code List PBCWA, Pg 700 Original policy
J0894Injection, decitabine, 1 mgClinical Review by Code List PBCWA, Pg 700 Original policy
J0896Injection, luspatercept-aamt, 0.25 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 700 Original policy
J0897Injection, denosumab, 1 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J0901Vadadustat, oral, 1 mg (for esrd on dialysis)Clinical Review by Code List PBCWA, Pg 701 Original policy
J1072Injection, testosterone cypionate (Azmiro), 1 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J1073Testosterone pellet, implant, 75 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J1201Injection, cetirizine HCl, 0.5 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J1202Miglustat, oral, 65 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J1203Injection, cipaglucosidase alfa-atga, 5 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J1289Injection, narsoplimab-wuug, 1 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J1290Injection, ecallantide, 1 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J1299Injection, eculizumab, 2 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J1300Injection, eculizumab, 10 mgClinical Review by Code List PBCWA, Pg 701 Original policy
J1302Injection, sutimlimab-jome, 10 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 701 Original policy
J1303Injection, ravulizumab-cwvz, 10 mgClinical Review by Code List PBCWA, Pg 702 Original policy
J1304Injection, tofersen, 1 mgClinical Review by Code List PBCWA, Pg 702 Original policy
J1305Injection, evinacumab-dgnb, 5 mgClinical Review by Code List PBCWA, Pg 702 Original policy
J1306Injection, inclisiran, 1 mgClinical Review by Code List PBCWA, Pg 702 Original policy
J1307Injection, crovalimab-akkz, 10 mgClinical Review by Code List PBCWA, Pg 702 Original policy
J1322Injection, elosulfase alfa, 1 mgClinical Review by Code List PBCWA, Pg 702 Original policy
J1323Injection, elranatamab-bcmm, 1 mgClinical Review by Code List PBCWA, Pg 702 Original policy
J1325Injection, epoprostenol, 0.5 mgClinical Review by Code List PBCWA, Pg 702 Original policy
J1326Injection, zolbetuximab-clzb, 2 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 702 Original policy
J1411Injection, etranacogene dezaparvovec-drlb, per therapeutic doseClinical Review by Code List PBCWA, Pg 703 Original policy
J1412Injection, valoctocogene roxaparvovec- rvox, per ml, containing nominal 2x10^13 vector genomesClinical Review by Code List PBCWA, Pg 703 Original policy
J1413Injection, delandistrogene moxeparvovec- rokl, per therapeutic doseClinical Review by Code List PBCWA, Pg 703 Original policy
J1426Injection, casimersen, 10 mgClinical Review by Code List PBCWA, Pg 703 Original policy
J1427Injection, Viltolarsen, 10mgClinical Review by Code List PBCWA, Pg 703 Original policy
J1428Injection, eteplirsen, 10 mgClinical Review by Code List PBCWA, Pg 703 Original policy
J1429Injection, golodirsen, 10 mgClinical Review by Code List PBCWA, Pg 703 Original policy
J1437Injection, ferric derisomaltose, 10 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 703 Original policy
J1438Injection Etanercept (Enbrel) 25 MGClinical Review by Code List PBCWA, Pg 704 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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