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Anthem Blue Cross and Blue Shield Nevada prior authorization code reference, page 73

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
J3397Injection, vestronidase alfa-vjbk, 1 mgNevada Prior Authorization List, Pg 151 Original policy
J3398Injection, voretigene neparvovec-rzyl, 1 billion vector genomesNevada Prior Authorization List, Pg 151 Original policy
J3399Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomesNevada Prior Authorization List, Pg 151 Original policy
J3401Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector genomes, per 0.1 mlNevada Prior Authorization List, Pg 151 Original policy
J3402Injection, remestemcel-l-rknd, per therapeutic doseNevada Prior Authorization List, Pg 151 Original policy
J3403Revakinagene taroretcel-lwey, per implantNevada Prior Authorization List, Pg 151 Original policy
J3489Injection, zoledronic acid, 1 mgNevada Prior Authorization List, Pg 151 Original policy
J7170Injection, emicizumab-kxwh, 0.5 mgNevada Prior Authorization List, Pg 151 Original policy
J7171Injection, ADAMTS13, recombinant-krhn, 10 IUNevada Prior Authorization List, Pg 151 Original policy
J7172Injection, marstacimab-hncq, 0.5 mgNevada Prior Authorization List, Pg 151 Original policy
J7173Injection, concizumab-mtci, 0.5 mgNevada Prior Authorization List, Pg 151 Original policy
J7174Injection, fitusiran, 0.04 mgNevada Prior Authorization List, Pg 151 Original policy
J7175Injection, factor x, (human), 1 i.u.Nevada Prior Authorization List, Pg 151 Original policy
J7177Injection, human fibrinogen concentrate (Fibryga), 1 mgNevada Prior Authorization List, Pg 151 Original policy
J7178Injection, human fibrinogen concentrate, not otherwise specified, 1 mgNevada Prior Authorization List, Pg 151 Original policy
J7179Injection, von willebrand factor (recombinant), (vonvendi), 1 i.u. vwf:rcoNevada Prior Authorization List, Pg 151 Original policy
J7180Injection, factor XIII (antihemophilic factor, human), 1 IUNevada Prior Authorization List, Pg 151 Original policy
J7181Injection, factor xiii a-subunit, (recombinant), per iuNevada Prior Authorization List, Pg 151 Original policy
J7182Injection, factor viii, (antihemophilic factor, recombinant), (novoeight), per iuNevada Prior Authorization List, Pg 151 Original policy
J7183Injection, von Willebrand factor complex (human), Wilate, 1 IU vWF:RCoNevada Prior Authorization List, Pg 151 Original policy
J7185Injection, Factor Viii (Antihemophilic Factor, Recombinant) (Xyntha), Per I.U.Nevada Prior Authorization List, Pg 151 Original policy
J7186Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per factor VIII i.u.Nevada Prior Authorization List, Pg 151 Original policy
J7187Injection, von Willebrand factor complex (Humate-P), per IU vWF-RC0Nevada Prior Authorization List, Pg 151 Original policy
J7188Injection, factor viii (antihemophilic factor, recombinant), (obizur), per i.u.Nevada Prior Authorization List, Pg 151 Original policy
J7189Factor VIIa (antihemophilic Factor, recombinant), per 1 mcgNevada Prior Authorization List, Pg 151 Original policy
J7190Factor ViiiNevada Prior Authorization List, Pg 151 Original policy
J7191Factor Viii (Porcine)Nevada Prior Authorization List, Pg 151 Original policy
J7192Factor Viii (Antihemophilic Factor, Recombinant) Per I.U., Not Otherwise SpecifiedNevada Prior Authorization List, Pg 151 Original policy
J7193Factor IX (antihemophilic factor, purified, non-recombinant) per IUNevada Prior Authorization List, Pg 151 Original policy
J7194Factor Ix ComplexNevada Prior Authorization List, Pg 151 Original policy
J7195Factor IX (antihemophilic factor, recombinant) per IUNevada Prior Authorization List, Pg 151 Original policy
J7198Anti-InhibitorNevada Prior Authorization List, Pg 151 Original policy
J7200Injection, factor ix, (antihemophilic factor, recombinant), rixubis, per iuNevada Prior Authorization List, Pg 151 Original policy
J7201Injection, factor IX, Fc fusion protein, (recombinant), Alprolix, 1 IUNevada Prior Authorization List, Pg 151 Original policy
J7202Injection, factor ix, albumin fusion protein, (recombinant), idelvion, 1 i.u.Nevada Prior Authorization List, Pg 151 Original policy
J7203Injection Factor IX, (antihemophilic factor, recombinant), glycopegylated, (Rebinyn), 1 IUNevada Prior Authorization List, Pg 151 Original policy
J7204Injection, Factor VIII, antihemophilic factor (recombinant), (Esperoct), glycopegylated-exei, per IUNevada Prior Authorization List, Pg 151 Original policy
J7205Injection, factor viii fc fusion (recombinant), per iuNevada Prior Authorization List, Pg 151 Original policy
J7207Injection, factor viii, (antihemophilic factor, recombinant), pegylated, 1 i.u.Nevada Prior Authorization List, Pg 151 Original policy
J7208Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u.Nevada Prior Authorization List, Pg 151 Original policy
J7209Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u.Nevada Prior Authorization List, Pg 151 Original policy
J7210Injection, Factor VIII, (antihemophilic factor, recombinant), (Afstyla), 1 IUNevada Prior Authorization List, Pg 151 Original policy
J7211Injection, Factor VIII, (antihemophilic factor, recombinant), (Kovaltry), 1 IUNevada Prior Authorization List, Pg 152 Original policy
J7212Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgramNevada Prior Authorization List, Pg 152 Original policy
J7213Injection, coagulation factor ix (recombinant), ixinity, 1 i.u.Nevada Prior Authorization List, Pg 152 Original policy
J7214Injection, Factor VIII/von Willebrand factor complex, recombinant (Altuviiio), per Factor VIII IUNevada Prior Authorization List, Pg 152 Original policy
J7311Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mgNevada Prior Authorization List, Pg 152 Original policy
J7312Injection, dexamethasone, intravitreal implant, 0.1 mgNevada Prior Authorization List, Pg 152 Original policy
J7313Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mgNevada Prior Authorization List, Pg 152 Original policy
J7314Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mgNevada Prior Authorization List, Pg 152 Original policy

Sources

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