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Premera Blue Cross of Washington prior authorization, page 44

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
Q5114Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mgClinical Review by Code List PBCWA, Pg 806 Original policy
Q5115Injection, rituximab-abbs, biosimilar, (Truxima), 10 mgClinical Review by Code List PBCWA, Pg 806 Original policy
Q5116Injection, trastuzumab-qyyp, biosimilar, (Trazimera), 10 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 806 Original policy
Q5117Injection, trastuzumab-anns, biosimilar, (Kanjinti), 10 mgClinical Review by Code List PBCWA, Pg 807 Original policy
Q5118Injection, bevacizumab-bvcr, biosimilar, (Zirabev), 10 mgClinical Review by Code List PBCWA, Pg 807 Original policy
Q5119Injection, rituximab-pvvr, biosimilar, (RUXIENCE), 10 mgClinical Review by Code List PBCWA, Pg 807 Original policy
Q5120Injection, pegfilgrastim-bmez (ZIEXTENZO), biosimilar, 0.5 mgClinical Review by Code List PBCWA, Pg 807 Original policy
Q5121Injection, infliximab-axxq, biosimilar, (AVSOLA), 10 mgClinical Review by Code List PBCWA, Pg 807 Original policy
Q5122Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mgClinical Review by Code List PBCWA, Pg 807 Original policy
Q5123Injection, rituximab-arrx, biosimilar, (Riabni), 10 mgClinical Review by Code List PBCWA, Pg 807 Original policy
Q5124Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mgClinical Review by Code List PBCWA, Pg 807 Original policy
Q5125Injection, filgrastim-ayow, biosimilar, (Releuko), 1 mcgClinical Review by Code List PBCWA, Pg 807 Original policy
Q5126Injection, bevacizumab-maly, biosimilar, (Alymsys), 10 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 807 Original policy
Q5127Injection, Pegfilgrastim-fpgk (Stimufend), biosimilar, 0.5 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5128Injection, Ranibizumab-eqrn (Cimerli), biosimilar, 0.1 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5129Injection, Bevacizumab-adcd (Vegzelma), biosimilar, 10 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5130Injection, Pegfilgrastim-pbbk (Fylnetra), biosimilar, 0.5 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5133Injection, tocilizumab-bavi (tofidence), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5134Injection, natalizumab-sztn (tyruko), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5135Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5136Injection, denosumab-bbdz (Jubbonti/Wyost), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5137Injection, ustekinumab-auub (Wezlana), biosimilar, SC, 1 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5138Injection, ustekinumab-auub (Wezlana), biosimilar, IV, 1 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5140Injection, adalimumab-fkjp, biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 808 Original policy
Q5141Injection, adalimumab-aaty, biosimilar, 1 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 808 Original policy
Q5142Injection, adalimumab-ryvk biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5143Injection, adalimumab-adbm, biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5144Injection, adalimumab-aacf (idacio), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5145Injection, adalimumab-afzb (abrilada), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5146Injection, trastuzumab-strf (hercessi), biosimilar, 10 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5147Injection, aflibercept-ayyh (pavblu), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5148Injection, filgrastim-txid (nypozi), biosimilar, 1 microgramClinical Review by Code List PBCWA, Pg 809 Original policy
Q5149Injection, aflibercept-abzv (Enzeevu), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5150Injection, aflibercept-mrbb (Ahzantive), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5151Injection, eculizumab-aagh (Epysqli), biosimilar, 2 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5152Injection, eculizumab-aeeb (Bkemv), biosimilar, 2 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5153Injection, aflibercept-yszy (opuviz), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 809 Original policy
Q5154Injection, omalizumab-igec (Omlyclo), biosimilar, 5 mg These criteria do not imply or guarantee approval.Clinical Review by Code List PBCWA, Pg 809 Original policy
Q5155Injection, aflibercept-jbvf (Yesafili), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5156Injection, tocilizumab-anoh (Avtozma), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5157Injection, denosumab-bmwo (Stoboclo/Osenvelt), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5158Injection, denosumab-bnht (Bomyntra/Conexxence), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5159Injection, denosumab-dssb (Ospomyv/Xbryk), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5160Injection, bevacizumab-nwgd (Jobevne), biosimilar, 10 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5161Injection, denosumab-kyqq (aukelso/bosaya), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5162Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5164Injection, ustekinumab-hmny (Starjemza) Biosimilar, 1mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5165Injection, denosumab-mobz (Oziltus), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5166Injection, denosumab-desu (Osvyrti/Jubereq), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 Original policy
Q5167Injection, denosumab-qbde (Enoby/Xtrenbo), biosimilar, 1 mgClinical Review by Code List PBCWA, Pg 810 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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