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Anthem Blue Cross and Blue Shield Nevada prior authorization code reference, page 75

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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
J9217Leuprolide Acetate SuspnsionNevada Prior Authorization List, Pg 153 Original policy
J9223Injection, lurbinectedin, 0.1 mgNevada Prior Authorization List, Pg 153 Original policy
J9226Histrelin implant (supprelin LA), 50 mgNevada Prior Authorization List, Pg 153 Original policy
J9227Injection, isatuximab-irfc, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9228Injection, ipilimumab, 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9229Injection, inotuzumab ozogamicin, 0.1 mgNevada Prior Authorization List, Pg 153 Original policy
J9248Injection, melphalan (Hepzato), 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9256Injection, nipocalimab-aahu, 3 mgNevada Prior Authorization List, Pg 153 Original policy
J9262Injection, omacetaxine mepesuccinate, 0.01 mgNevada Prior Authorization List, Pg 153 Original policy
J9264Injection, paclitaxel protein-bound particles, 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9266Injection, pegaspargase, per single dose vialNevada Prior Authorization List, Pg 153 Original policy
J9269Injection, tagraxofusp-erzs, 10 microgramsNevada Prior Authorization List, Pg 153 Original policy
J9271Injection, pembrolizumab, 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9272Injection, dostarlimab-gxly, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9273Injection, tisotumab vedotin-tftv, 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9274Injection, tebentafusp-tebn, 1 microgramNevada Prior Authorization List, Pg 153 Original policy
J9275Injection, cosibelimab-ipdl, 2 mgNevada Prior Authorization List, Pg 153 Original policy
J9276Injection, zanidatamab-hrii, 2 mgNevada Prior Authorization List, Pg 153 Original policy
J9277Injection, pembrolizumab, 1 mg and berahyaluronidase alfa-pmphNevada Prior Authorization List, Pg 153 Original policy
J9281Mitomycin pyelocalyceal instillation, 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9282Mitomycin, intravesical instillation, 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9286Injection, glofitamab-gxbm, 2.5 mgNevada Prior Authorization List, Pg 153 Original policy
J9289Injection, nivolumab, 2 mg and hyaluronidase-nvhyNevada Prior Authorization List, Pg 153 Original policy
J9292Injection, pemetrexed dipotassium, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9294Injection, pemetrexed (Hospira), not therapeutically equivalent to J9305, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9296Injection, pemetrexed (Accord), not therapeutically equivalent to J9305, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9297Injection, pemetrexed (sandoz), not therapeutically equivalent to j9305, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9298Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mgNevada Prior Authorization List, Pg 153 Original policy
J9299Injection, nivolumab, 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9301Injection, obinutuzumab, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9302Injection, ofatumumab, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9303Injection, panitumumab, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9304Injection, pemetrexed (pemfexy), 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9305Injection, pemetrexed, NOS,10 mgNevada Prior Authorization List, Pg 153 Original policy
J9306Injection, pertuzumab, 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9308Injection, ramucirumab, 5 mgNevada Prior Authorization List, Pg 153 Original policy
J9309Injection, polatuzumab vedotin-piiq, 1 mgNevada Prior Authorization List, Pg 153 Original policy
J9312Injection, rituximab, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9314Injection, pemetrexed (Teva), not therapeutically equivalent to J9305, 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9316Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mgNevada Prior Authorization List, Pg 153 Original policy
J9317Injection, sacituzumab govitecan-hziy, 2.5 mgNevada Prior Authorization List, Pg 153 Original policy
J9318Injection, romidepsin, nonlyophilized, 0.1 mgNevada Prior Authorization List, Pg 153 Original policy
J9319Injection, romidepsin, lyophilized, 0.1 mgNevada Prior Authorization List, Pg 154 Original policy
J9321Injection, epcoritamab-bysp, 0.16 mgNevada Prior Authorization List, Pg 154 Original policy
J9322Injection, pemetrexed (BluePoint), not therapeutically equivalent to J9305, 10 mgNevada Prior Authorization List, Pg 154 Original policy
J9323Injection, pemetrexed (hospira) not therapeutically equivalent to j9305, 10 mgNevada Prior Authorization List, Pg 154 Original policy
J9324Injection, pemetrexed (pemrydi rtu), 10 mgNevada Prior Authorization List, Pg 154 Original policy
J9325Injection, talimogene laherparepvec, per 1 million plaque forming unitsNevada Prior Authorization List, Pg 154 Original policy
J9326Injection, telisotuzumab vedotin-tllv, 1 mgNevada Prior Authorization List, Pg 154 Original policy
J9329Injection, tislelizumab-jsgr, 1mgNevada Prior Authorization List, Pg 154 Original policy

Sources

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