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Premera Blue Cross of Washington prior authorization, page 37

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
J3358Ustekinumab, for intravenous injection, 1 mgClinical Review by Code List PBCWA, Pg 715 Original policy
J3380Injection, Vedolizumab, intravenous 1 mgClinical Review by Code List PBCWA, Pg 715 Original policy
J3385Injection, velaglucerase alfa, 100 units These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 715 Original policy
J3386Injection, etuvetidigene autotemcel, per treatmentClinical Review by Code List PBCWA, Pg 716 Original policy
J3387Injection, elivaldogene autotemcel, per treatmentClinical Review by Code List PBCWA, Pg 716 Original policy
J3389Topical administration, prademagene zamikeracel, per treatmentClinical Review by Code List PBCWA, Pg 716 Original policy
J3391Injection, atidarsagene autotemcel, per treatmentClinical Review by Code List PBCWA, Pg 716 Original policy
J3392Injection, exagamglogene autotemcel, per treatmentClinical Review by Code List PBCWA, Pg 716 Original policy
J3393Injection, betibeglogene autotemcel, per treatmentClinical Review by Code List PBCWA, Pg 716 Original policy
J3394Injection, lovotibeglogene autotemcel, per treatmentClinical Review by Code List PBCWA, Pg 716 Original policy
J3396Injection, verteporfin, 0.1 mgClinical Review by Code List PBCWA, Pg 716 Original policy
J3397Injection, vestronidase alfa-vjbk, 1 mgClinical Review by Code List PBCWA, Pg 716 Original policy
J3398Injection, voretigene neparvovec-rzyl, 1 billion vector genomesClinical Review by Code List PBCWA, Pg 716 Original policy
J3399Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomesClinical Review by Code List PBCWA, Pg 716 Original policy
J3401Beremagene geperpavec-svdt for topical administration, containing nominal 5x10^9 pfu/ml vector genomes, per 0.1 ml These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 716 Original policy
J3402Injection, remestemcel-l-rknd, per therapeutic doseClinical Review by Code List PBCWA, Pg 717 Original policy
J3403Revakinagene taroretcel-lwey, per implantClinical Review by Code List PBCWA, Pg 717 Original policy
J3404Injection, zopapogene imadenovec-drba suspension, per therapeutic doseClinical Review by Code List PBCWA, Pg 717 Original policy
J3406Injection, Omidubicel-onlv, (Omisirge), per therapeutic doseClinical Review by Code List PBCWA, Pg 717 Original policy
J7170Injection, emicizumab-kxwh, 0.5 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 717 Original policy
J7171Injection, adamts13, recombinant-krhn, 10 iuClinical Review by Code List PBCWA, Pg 718 Original policy
J7172Injection, marstacimab-hncq, 0.5 mgClinical Review by Code List PBCWA, Pg 718 Original policy
J7173Injection, concizumab-mtci, 0.5 mgClinical Review by Code List PBCWA, Pg 718 Original policy
J7174Injection, fitusiran, 0.04 mgClinical Review by Code List PBCWA, Pg 718 Original policy
J7311Injection, Fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mgClinical Review by Code List PBCWA, Pg 718 Original policy
J7312Injection, dexamethasone, intravitreal implant, 0.1 mgClinical Review by Code List PBCWA, Pg 718 Original policy
J7313Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mgClinical Review by Code List PBCWA, Pg 718 Original policy
J7314Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mgClinical Review by Code List PBCWA, Pg 718 Original policy
J7330Autologous cultured chondrocytes, implantClinical Review by Code List PBCWA, Pg 719 Original policy
J7336Capsaicin 8% patch, per sq cmClinical Review by Code List PBCWA, Pg 720 Original policy
J7351Injection, bimatoprost, intracameral implant, 1 mcgClinical Review by Code List PBCWA, Pg 720 Original policy
J7352Afamelanotide implant, 1 mgClinical Review by Code List PBCWA, Pg 720 Original policy
J7353Anacaulase-BCDB, 8.8% gel, 1 gramClinical Review by Code List PBCWA, Pg 720 Original policy
J7354Cantharidin for topical administration, 0.7%, single unit dose applicator (3.2 mg)Clinical Review by Code List PBCWA, Pg 720 Original policy
J7355Injection, travoprost, intracameral implant, 1 microgramClinical Review by Code List PBCWA, Pg 720 Original policy
J7356Injection, foscarbidopa 0.25 mg/foslevodopa 5 mgClinical Review by Code List PBCWA, Pg 720 Original policy
J7686Treprostinil, inhalation solution, FDA- approved final product, noncompounded, administered through DME, unit dose form, 1.74 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 720 Original policy
J8611Methotrexate (jylamvo), oral, 2.5 mgClinical Review by Code List PBCWA, Pg 721 Original policy
J8612Methotrexate (xatmep), oral, 2.5 mgClinical Review by Code List PBCWA, Pg 721 Original policy
J9003Leuprolide injectable (Camcevi ETM), 1 mgClinical Review by Code List PBCWA, Pg 721 Original policy
J9011Injection, datopotamab deruxtecan-dlnk, 1 mgClinical Review by Code List PBCWA, Pg 721 Original policy
J9017Injection, arsenic trioxide, 1 mgClinical Review by Code List PBCWA, Pg 721 Original policy
J9021Injection, asparaginase, recombinant, (Rylaze), 0.1 mgClinical Review by Code List PBCWA, Pg 721 Original policy
J9022Injection, atezolizumab, 10 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 721 Original policy
J9023Injection, avelumab, 10 mgClinical Review by Code List PBCWA, Pg 722 Original policy
J9024Injection, atezolizumab, 5 mg and hyaluronidase-tqjsClinical Review by Code List PBCWA, Pg 722 Original policy
J9026Injection, tarlatamab-dlle, 1 mgClinical Review by Code List PBCWA, Pg 722 Original policy
J9027Injection, clofarabine, 1 mgClinical Review by Code List PBCWA, Pg 722 Original policy
J9028Injection, nogapendekin alfa inbakicept- pmln, for intravesical use, 1 microgramClinical Review by Code List PBCWA, Pg 722 Original policy
J9029Intravesical instillation, nadofaragene firadenovec-vncg, per therapeutic doseClinical Review by Code List PBCWA, Pg 722 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.

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