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Anthem Blue Cross and Blue Shield Nevada prior authorization code reference, page 72

Source code lookup

Each row links an imported source code to its service or category label. Check the original document for the complete plan scope, review type and qualifications.

Source code index

Imported source codes and labels; verify the complete review requirements in the original document
CodeDescriptionSource
J2350Injection, ocrelizumab, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2351Injection, ocrelizumab, 1 mg and hyaluronidase-ocsqNevada Prior Authorization List, Pg 150 Original policy
J2353Injection, octreotide, depot form for intramuscular injection, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2354Injection, octreotide, non-depot form for subcutaneous or intravenousNevada Prior Authorization List, Pg 150 Original policy
J2356Injection, tezepelumab-ekko, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2357Omalizumab injectionNevada Prior Authorization List, Pg 150 Original policy
J2502Injection, pasireotide long acting, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2505Injection, pegfilgrastim, 6 mgNevada Prior Authorization List, Pg 150 Original policy
J2506Injection, pegfilgrastim, excludes biosimilar, 0.5 mgNevada Prior Authorization List, Pg 150 Original policy
J2507Injection, pegloticase, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2508Injection, pegunigalsidase alfa-iwxj, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2510Penicillin G Procaine InjNevada Prior Authorization List, Pg 150 Original policy
J2540Penicillin G Potassium InjNevada Prior Authorization List, Pg 150 Original policy
J2562Injection, Plerixafor, 1 MgNevada Prior Authorization List, Pg 150 Original policy
J2777Injection, faricimab-svoa, 0.1 mgNevada Prior Authorization List, Pg 150 Original policy
J2778Injection, ranibizumab, 0.1 mgNevada Prior Authorization List, Pg 150 Original policy
J2779Injection, ranibizumab, via intravitreal implant (susvimo), 0.1 mgNevada Prior Authorization List, Pg 150 Original policy
J2781Injection, pegcetacoplan, intravitreal, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2782Injection, avacincaptad pegol, 0.1 mgNevada Prior Authorization List, Pg 150 Original policy
J2786Injection, reslizumab, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2787Riboflavin 5'-phosphate, ophthalmic solution (photrexa viscous/photrexa), up to 3 mlNevada Prior Authorization List, Pg 150 Original policy
J2793Injection, Rilonacept, 1 MgNevada Prior Authorization List, Pg 150 Original policy
J2796Injection, Romiplostim, 10 MicrogramsNevada Prior Authorization List, Pg 150 Original policy
J2802Injection, romiplostim, 1 microgramNevada Prior Authorization List, Pg 150 Original policy
J2820Sargramostim InjectionNevada Prior Authorization List, Pg 150 Original policy
J2840Injection, sebelipase alfa, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2940Injection, somatrem, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2941Injection, somatropin, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J2998Injection, plasminogen, human-tvmh, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3032Injection, eptinezumab-jjmr, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3055Injection, talquetamab-tgvs, 0.25 mgNevada Prior Authorization List, Pg 150 Original policy
J3060Injection, taliglucerace alfa, 10 unitsNevada Prior Authorization List, Pg 150 Original policy
J3111Injection, romosozumab-aqqg, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3241Injection, teprotumumab-trbw, 10 mgNevada Prior Authorization List, Pg 150 Original policy
J3245Injection, tildrakizumab, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3247Injection, secukinumab, IV, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3262Injection, tocilizumab, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3263Injection, toripalimab-tpzi, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3285Injection, treprostinil, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3299Injection, triamcinolone acetonide (xipere), 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3304Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3316Injection, triptorelin, extended-release, 3.75 mgNevada Prior Authorization List, Pg 150 Original policy
J3357Ustekinumab, for subcutaneous injection, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3358Ustekinumab, for intravenous injection, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3380Injection, vedolizumab, IV, 1 mgNevada Prior Authorization List, Pg 150 Original policy
J3385Injection, velaglucerase alfa, 100 unitsNevada Prior Authorization List, Pg 150 Original policy
J3391Injection, atidarsagene autotemcel, per treatmentNevada Prior Authorization List, Pg 150 Original policy
J3392Injection, exagamglogene autotemcel, per treatmentNevada Prior Authorization List, Pg 150 Original policy
J3393Injection, betibeglogene autotemcel, per treatmentNevada Prior Authorization List, Pg 150 Original policy
J3394Injection, lovotibeglogene autotemcel, per treatmentNevada Prior Authorization List, Pg 150 Original policy

Sources

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