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Premera Blue Cross of Washington prior authorization, page 35

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
J1439Injection, ferric carboxymaltose, 1 mgClinical Review by Code List PBCWA, Pg 704 Original policy
J1440Fecal microbiota, live - jslm, 1 mlClinical Review by Code List PBCWA, Pg 704 Original policy
J1442Injection, filgrastim (G-CSF), excludes biosimilars, 1 microgramClinical Review by Code List PBCWA, Pg 704 Original policy
J1448Injection, trilaciclib, 1 mgClinical Review by Code List PBCWA, Pg 704 Original policy
J1449Injection, eflapegrastim-xnst, 0.1 mgClinical Review by Code List PBCWA, Pg 704 Original policy
J1458Injection, galsulfase, 1 mgClinical Review by Code List PBCWA, Pg 704 Original policy
J1459Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 704 Original policy
J1551Injection, immune globulin (Cutaquig), 100 mgClinical Review by Code List PBCWA, Pg 705 Original policy
J1552Injection, immune globulin (alyglo), 500 mgClinical Review by Code List PBCWA, Pg 705 Original policy
J1553Injection, immune globulin (yimmugo), 100 mgClinical Review by Code List PBCWA, Pg 705 Original policy
J1554Injection, immune globulin (asceniv), 500 mgClinical Review by Code List PBCWA, Pg 705 Original policy
J1555Injection, immune globulin (Cuvitru), 100 mgClinical Review by Code List PBCWA, Pg 705 Original policy
J1556Injection, immune globulin (bivigam), 500 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 705 Original policy
J1557Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mgClinical Review by Code List PBCWA, Pg 706 Original policy
J1558Injection, immune globulin (xembify), 100 mgClinical Review by Code List PBCWA, Pg 706 Original policy
J1559Injection, immune globulin (Hizentra), 100 mgClinical Review by Code List PBCWA, Pg 706 Original policy
J1561Injection, immune globulin, (Gamunex), intravenous, nonlyophilized (e.g., liquid), 500 mgClinical Review by Code List PBCWA, Pg 706 Original policy
J1566Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mgClinical Review by Code List PBCWA, Pg 706 Original policy
J1568Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mgClinical Review by Code List PBCWA, Pg 706 Original policy
J1569Injection, immune globulin, (Gammagard liquid) nonlyophilized, (e.g., liquid), 500 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 706 Original policy
J1575Injection, immune globulin/Hyaluronidase, (HYQVIA), 100 MG immune globulinClinical Review by Code List PBCWA, Pg 707 Original policy
J1576Injection, immune globulin (panzyga), intravenous, non-lyophilized (e.g., liquid), 500 mgClinical Review by Code List PBCWA, Pg 707 Original policy
J1577Injection, immune globulin (Qivigy), 100 mgClinical Review by Code List PBCWA, Pg 707 Original policy
J1595Injection, glatiramer acetate, 20 mgClinical Review by Code List PBCWA, Pg 707 Original policy
J1599Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mgClinical Review by Code List PBCWA, Pg 707 Original policy
J1602Injection, golimumab, 1 mg, for intravenous useClinical Review by Code List PBCWA, Pg 707 Original policy
J1628Injection, guselkumab, 1 mgClinical Review by Code List PBCWA, Pg 707 Original policy
J1632Injection, brexanolone, 1 mgClinical Review by Code List PBCWA, Pg 707 Original policy
J1743Injection, idursulfase, 1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 707 Original policy
J1744Injection, icatibant, 1 mgClinical Review by Code List PBCWA, Pg 708 Original policy
J1745Injection, infliximab, excludes biosimilar, 10 mgClinical Review by Code List PBCWA, Pg 708 Original policy
J1747Injection, Spesolimab-sbzo, 1 mgClinical Review by Code List PBCWA, Pg 708 Original policy
J1748Injection, infliximab-dyyb (Zymfentra), 10 mgClinical Review by Code List PBCWA, Pg 708 Original policy
J1786Injection, imiglucerase, 10 unitsClinical Review by Code List PBCWA, Pg 708 Original policy
J1809Injection, fosdenopterin, 0.1 mgClinical Review by Code List PBCWA, Pg 708 Original policy
J1813Insulin (lyumjev) for administration through dme (i.e., insulin pump) per 50 unitsClinical Review by Code List PBCWA, Pg 708 Original policy
J1814Insulin (lyumjev), per 5 unitsClinical Review by Code List PBCWA, Pg 708 Original policy
J1823Injection, inebilizumab-cdon, 1 mgClinical Review by Code List PBCWA, Pg 708 Original policy
J1826Injection, interferon beta-1a, 30 mcg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 708 Original policy
J1830Injection interferon beta-1b, 0.25 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 709 Original policy
J1930Injection, lanreotide, 1 mgClinical Review by Code List PBCWA, Pg 709 Original policy
J1931Injection, laronidase, 0.1 mgClinical Review by Code List PBCWA, Pg 709 Original policy
J1932Injection, lanreotide, (Cipla), 1 mgClinical Review by Code List PBCWA, Pg 709 Original policy
J1950Injection, leuprolide acetate (for depot suspension), per 3.75 mgClinical Review by Code List PBCWA, Pg 709 Original policy
J1951Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mgClinical Review by Code List PBCWA, Pg 709 Original policy
J1952Leuprolide injectable, camcevi, 1 mgClinical Review by Code List PBCWA, Pg 709 Original policy
J1954Injection, leuprolide acetate for depot suspension (Cipla), 7.5 mgClinical Review by Code List PBCWA, Pg 709 Original policy
J2170Injection, mecasermin, 1 mgClinical Review by Code List PBCWA, Pg 709 Original policy
J2182Injection, Mepolizumab, 1 MG These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 709 Original policy
J2267Injection, mirikizumab-mrkz, 1 mgClinical Review by Code List PBCWA, Pg 710 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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