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Premera Blue Cross of Washington prior authorization, page 36

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
J2277Injection, motixafortide, 0.25 mgClinical Review by Code List PBCWA, Pg 710 Original policy
J2278Injection, ziconotide, 1 mcgClinical Review by Code List PBCWA, Pg 710 Original policy
J2323Injection, natalizumab, 1 mgClinical Review by Code List PBCWA, Pg 710 Original policy
J2326Injection, nusinersen, 0.1 mgClinical Review by Code List PBCWA, Pg 710 Original policy
J2329Injection, ublituximab-xiiy, 1mgClinical Review by Code List PBCWA, Pg 710 Original policy
J2350Injection, ocrelizumab, 1 mgClinical Review by Code List PBCWA, Pg 710 Original policy
J2351Injection, ocrelizumab, 1 mg and hyaluronidase-ocsqClinical Review by Code List PBCWA, Pg 710 Original policy
J2353Injection, octreotide, depot form for intramuscular injection, 1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 710 Original policy
J2354Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcgClinical Review by Code List PBCWA, Pg 711 Original policy
J2356Injection, tezepelumab-ekko, 1 mgClinical Review by Code List PBCWA, Pg 711 Original policy
J2357Injection, omalizumab, 5 mgClinical Review by Code List PBCWA, Pg 711 Original policy
J2361Injection, depemokimab-ulaa, 1 mgClinical Review by Code List PBCWA, Pg 711 Original policy
J2425Injection, palifermin, 50 mcgClinical Review by Code List PBCWA, Pg 711 Original policy
J2502Injection, Pasireotide Long Acting, 1 MGClinical Review by Code List PBCWA, Pg 711 Original policy
J2506Injection, pegfilgrastim, excludes biosimilar, 0.5 mgClinical Review by Code List PBCWA, Pg 711 Original policy
J2507Injection, pegloticase, 1 mgClinical Review by Code List PBCWA, Pg 711 Original policy
J2508Injection, pegunigalsidase alfa-iwxj, 1 mgClinical Review by Code List PBCWA, Pg 711 Original policy
J2777Injection, faricimab-svoa, 0.1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 711 Original policy
J2778Injection, ranibizumab, 0.1 mgClinical Review by Code List PBCWA, Pg 712 Original policy
J2779Injection, ranibizumab, via intravitreal implant (Susvimo), 0.1 mgClinical Review by Code List PBCWA, Pg 712 Original policy
J2781Injection, Pegcetacoplan, intravitreal, 1 mgClinical Review by Code List PBCWA, Pg 712 Original policy
J2782Injection, avacincaptad pegol, 0.1 mgClinical Review by Code List PBCWA, Pg 712 Original policy
J2783Injection, rasburicase, 0.5 mgClinical Review by Code List PBCWA, Pg 712 Original policy
J2786Injection, reslizumab, 1 mgClinical Review by Code List PBCWA, Pg 712 Original policy
J2792Injection, Rho D immune globulin, intravenous, human, solvent detergent, 100 IUClinical Review by Code List PBCWA, Pg 712 Original policy
J2793Injection, rilonacept, 1 mgClinical Review by Code List PBCWA, Pg 712 Original policy
J2802Injection, romiplostim, 1 microgramClinical Review by Code List PBCWA, Pg 712 Original policy
J2820Injection, sargramostim (GM-CSF), 50 mcgClinical Review by Code List PBCWA, Pg 712 Original policy
J2840Injection, sebelipase alfa, 1 mgClinical Review by Code List PBCWA, Pg 712 Original policy
J2860Injection, siltuximab, 10 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 712 Original policy
J2941Injection, somatropin, 1 mgClinical Review by Code List PBCWA, Pg 713 Original policy
J2998Injection, plasminogen, human-tvmh, 1 mgClinical Review by Code List PBCWA, Pg 713 Original policy
J3031Injection, fremanezumab-vfrm, 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 713 Original policy
J3032Injection, eptinezumab-jjmr, 1 mgClinical Review by Code List PBCWA, Pg 713 Original policy
J3055Injection, talquetamab-tgvs, 0.25 mgClinical Review by Code List PBCWA, Pg 713 Original policy
J3060Injection, taliglucerase alfa, 10 units These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 713 Original policy
J3110Injection, teriparatide, 10 mcgClinical Review by Code List PBCWA, Pg 714 Original policy
J3111Injection, romosozumab-aqqg, 1 mgClinical Review by Code List PBCWA, Pg 714 Original policy
J3145Injection, testosterone undecanoate, 1 mgClinical Review by Code List PBCWA, Pg 714 Original policy
J3241Injection, teprotumumab-trbw, 10 mgClinical Review by Code List PBCWA, Pg 714 Original policy
J3245Injection, tildrakizumab, 1 mgClinical Review by Code List PBCWA, Pg 714 Original policy
J3247Injection, secukinumab, intravenous, 1 mgClinical Review by Code List PBCWA, Pg 714 Original policy
J3262Injection, tocilizumab, 1 mg (Actemra)Clinical Review by Code List PBCWA, Pg 714 Original policy
J3263Injection, toripalimab-tpzi, 1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 714 Original policy
J3285Injection, treprostinil, 1 mgClinical Review by Code List PBCWA, Pg 715 Original policy
J3299Injection, triamcinolone acetonide (Xipere), 1 mgClinical Review by Code List PBCWA, Pg 715 Original policy
J3304Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mgClinical Review by Code List PBCWA, Pg 715 Original policy
J3315Injection, triptorelin pamoate, 3.75 mgClinical Review by Code List PBCWA, Pg 715 Original policy
J3316Injection, triptorelin, extended-release, 3.75 mgClinical Review by Code List PBCWA, Pg 715 Original policy
J3357Ustekinumab, for subcutaneous injection, 1 mgClinical Review by Code List PBCWA, Pg 715 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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