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Premera Blue Cross of Washington prior authorization, page 39

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
J9227Injection, isatuximab-irfc, 10 mgClinical Review by Code List PBCWA, Pg 726 Original policy
J9228Injection, ipilimumab, 1 mgClinical Review by Code List PBCWA, Pg 726 Original policy
J9229Injection, inotuzumab ozogamicin, 0.1 mgClinical Review by Code List PBCWA, Pg 726 Original policy
J9246Injection, melphalan (Evomela), 1 mgClinical Review by Code List PBCWA, Pg 726 Original policy
J9248Injection, melphalan (hepzato), 1 mgClinical Review by Code List PBCWA, Pg 726 Original policy
J9249Injection, melphalan (Apotex), 1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 726 Original policy
J9256Injection, nipocalimab-aahu, 3 mgClinical Review by Code List PBCWA, Pg 727 Original policy
J9258Injection, paclitaxel protein-bound particles (Teva), not therapeutically equivalent to J9264, 1 mgClinical Review by Code List PBCWA, Pg 727 Original policy
J9261Injection, nelarabine, 50 mgClinical Review by Code List PBCWA, Pg 727 Original policy
J9264Injection, paclitaxel protein-bound particles, 1 mgClinical Review by Code List PBCWA, Pg 727 Original policy
J9266Injection, pegaspargase, per single dose vialClinical Review by Code List PBCWA, Pg 727 Original policy
J9268Injection, pentostatin, 10 mgClinical Review by Code List PBCWA, Pg 727 Original policy
J9269Injection, tagraxofusp-erzs, 10 mcgClinical Review by Code List PBCWA, Pg 727 Original policy
J9271Injection, pembrolizumab, 1 mgClinical Review by Code List PBCWA, Pg 727 Original policy
J9272Injection, dostarlimab-gxly, 10 mgClinical Review by Code List PBCWA, Pg 727 Original policy
J9273Injection, tisotumab vedotin-tftv, 1 mgClinical Review by Code List PBCWA, Pg 727 Original policy
J9274Injection, tebentafusp-tebn, 1 mcgClinical Review by Code List PBCWA, Pg 727 Original policy
J9275Injection, cosibelimab-ipdl, 2 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 727 Original policy
J9276Injection, zanidatamab-hrii, 2 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9277Injection, pembrolizumab, 1 mg and berahyaluronidase alfa-pmph (Keytruda Qlex)Clinical Review by Code List PBCWA, Pg 728 Original policy
J9281Mitomycin pyelocalyceal instillation, 1 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9282Mitomycin, intravesical instillation, 1 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9285Injection, olaratumab, 10 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9286Injection, glofitamab-gxbm, 2.5 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9289Injection, nivolumab, 2 mg and hyaluronidase-nvhyClinical Review by Code List PBCWA, Pg 728 Original policy
J9292Injection, pemetrexed (avyxa), not therapeutically equivalent to j9305, 10 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9294Injection, Pemetrexed (Hospira), 10 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9295Injection, necitumumab, 1 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9296Injection, Pemetrexed (Accord), 10 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9297Injection, Pemetrexed (Sandoz), 10 mgClinical Review by Code List PBCWA, Pg 728 Original policy
J9299Injection, Nivolumab, 1 MGClinical Review by Code List PBCWA, Pg 729 Original policy
J9301Injection, obinutuzumab, 10 mgClinical Review by Code List PBCWA, Pg 729 Original policy
J9302Injection, ofatumumab, 10 mg (Arzerra)Clinical Review by Code List PBCWA, Pg 729 Original policy
J9303Injection, panitumumab, 10 mgClinical Review by Code List PBCWA, Pg 729 Original policy
J9304Injection, pemetrexed (Pemfexy), 10 mgClinical Review by Code List PBCWA, Pg 729 Original policy
J9305Injection, pemetrexed, 10 mgClinical Review by Code List PBCWA, Pg 729 Original policy
J9306Injection, pertuzumab, 1 mgClinical Review by Code List PBCWA, Pg 729 Original policy
J9307Injection, pralatrexate, 1 mgClinical Review by Code List PBCWA, Pg 729 Original policy
J9308Injection, ramucirumab, 5 mgClinical Review by Code List PBCWA, Pg 729 Original policy
J9309Injection, polatuzumab vedotin-piiq, 1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 729 Original policy
J9311Injection, rituximab 10 mg and hyaluronidaseClinical Review by Code List PBCWA, Pg 730 Original policy
J9312Injection, rituximab, 10 mgClinical Review by Code List PBCWA, Pg 730 Original policy
J9313Injection, moxetumomab pasudotox-tdfk, 0.01 mgClinical Review by Code List PBCWA, Pg 730 Original policy
J9314Injection, pemetrexed (Teva) not therapeutically equivalent to J9305, 10 mgClinical Review by Code List PBCWA, Pg 730 Original policy
J9316Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mgClinical Review by Code List PBCWA, Pg 730 Original policy
J9317Injection, sacituzumab govitecan-hziy, 2.5 mgClinical Review by Code List PBCWA, Pg 730 Original policy
J9318Injection, romidepsin, nonlyophilized, 0.1 mgClinical Review by Code List PBCWA, Pg 730 Original policy
J9319Injection, romidepsin, lyophilized, 0.1 mgClinical Review by Code List PBCWA, Pg 730 Original policy
J9321Injection, epcoritamab-bysp, 0.16 mgClinical Review by Code List PBCWA, Pg 730 Original policy
J9322Injection, pemetrexed (BluePoint) not therapeutically equivalent to J9305, 10 mgClinical Review by Code List PBCWA, Pg 730 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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