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Premera Blue Cross of Washington prior authorization, page 38

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
J9032Injection, Belinostat, 10 MGClinical Review by Code List PBCWA, Pg 722 Original policy
J9033Injection, Bendamustine Hydrochloride, not otherwise specified, 1mgClinical Review by Code List PBCWA, Pg 722 Original policy
J9034Injection, bendamustine HCl (Bendeka), 1 mgClinical Review by Code List PBCWA, Pg 722 Original policy
J9035Injection, bevacizumab, 10 mgClinical Review by Code List PBCWA, Pg 722 Original policy
J9036Injection, bendamustine HCl, (Belrapzo/bendamustine), 1 mgClinical Review by Code List PBCWA, Pg 722 Original policy
J9038Injection, axatilimab-csfr, 0.1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 722 Original policy
J9039Injection, blinatumomab, 1 mcgClinical Review by Code List PBCWA, Pg 723 Original policy
J9041Injection, bortezomib, 0.1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9042Injection, brentuximab vedotin, 1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9043Injection, cabazitaxel, 1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9046Injection, bortezomib (Dr. Reddy's), not therapeutically equivalent to J9041, 0.1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9047Injection, carfilzomib, 1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9048Injection, bortezomib (Fresenius Kabi), not therapeutically equivalent to J9041, 0.1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9049Injection, bortezomib (Hospira), not therapeutically equivalent to J9041, 0.1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9051Injection, Bortezomib (MAIA), not therapeutically equivalent to J9041, 0.1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9053Injection, belantamab mafodotin-blmf, 0.1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9054Injection, bortezomib (boruzu), 0.1 mgClinical Review by Code List PBCWA, Pg 723 Original policy
J9055Injection, cetuximab, 10 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 723 Original policy
J9056Injection, bendamustine HCl (Vivimusta), 1 mgClinical Review by Code List PBCWA, Pg 724 Original policy
J9057Injection, copanlisib, 1 mgClinical Review by Code List PBCWA, Pg 724 Original policy
J9061Injection, amivantamab-vmjw, 2 mgClinical Review by Code List PBCWA, Pg 724 Original policy
J9062Injection, amivantamab 5 mg and hyaluronidase-lpujClinical Review by Code List PBCWA, Pg 724 Original policy
J9063Injection, mirvetuximab soravtansine-gynx, 1 mgClinical Review by Code List PBCWA, Pg 724 Original policy
J9118Injection, calaspargase pegol-mknl, 10 unitsClinical Review by Code List PBCWA, Pg 724 Original policy
J9119Injection, cemiplimab-rwlc, 1 mgClinical Review by Code List PBCWA, Pg 724 Original policy
J9120Injection, dactinomycin, 0.5 mgClinical Review by Code List PBCWA, Pg 724 Original policy
J9144Injection, daratumumab, 10 mg and hyaluronidase-fihjClinical Review by Code List PBCWA, Pg 724 Original policy
J9145Injection, daratumumab, 10 mgClinical Review by Code List PBCWA, Pg 724 Original policy
J9153Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabineClinical Review by Code List PBCWA, Pg 724 Original policy
J9155Injection, degarelix, 1 mgClinical Review by Code List PBCWA, Pg 724 Original policy
J9161Injection, denileukin diftitox-cxdl, 1 mcg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 724 Original policy
J9172Injection, docetaxel (Docivyx), 1 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9173Injection, durvalumab, 10 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9174Injection, docetaxel (Beizray), 1 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9176Injection, elotuzumab, 1 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9177Injection, enfortumab vedotin-ejfv, 0.25 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9179Injection, eribulin mesylate, 0.1 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9183Gemcitabine intravesical system, 225 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9200Injection, floxuridine, 500 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9202Goserelin acetate implant, per 3.6 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9203Injection, gemtuzumab ozogamicin, 0.1 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9204Injection, mogamulizumab-kpkc, 1 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9205Injection, irinotecan liposome, 1 mgClinical Review by Code List PBCWA, Pg 725 Original policy
J9207Injection, ixabepilone, 1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 725 Original policy
J9210Injection, emapalumab-lzsg, 1 mgClinical Review by Code List PBCWA, Pg 726 Original policy
J9216Injection, interferon, gamma 1-b, 3 million unitsClinical Review by Code List PBCWA, Pg 726 Original policy
J9217Leuprolide acetate (for depot suspension), 7.5 mgClinical Review by Code List PBCWA, Pg 726 Original policy
J9218Leuprolide acetate, per 1 mgClinical Review by Code List PBCWA, Pg 726 Original policy
J9223Injection, lurbinectedin, 0.1 mgClinical Review by Code List PBCWA, Pg 726 Original policy
J9226Histrelin implant (Supprelin LA), 50 mgClinical Review by Code List PBCWA, Pg 726 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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