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Anthem Blue Cross and Blue Shield Nevada prior authorization code reference, page 84

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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
Q5105Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for ESRD on dialysis), 100 unitsNevada Prior Authorization List, Pg 167 Original policy
Q5106Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD use), 1000 unitsNevada Prior Authorization List, Pg 167 Original policy
Q5107Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5108Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mgNevada Prior Authorization List, Pg 167 Original policy
Q5109Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5110Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgramNevada Prior Authorization List, Pg 167 Original policy
Q5111Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mgNevada Prior Authorization List, Pg 167 Original policy
Q5112Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5113Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5114Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5115Injection, rituximab-abbs, biosimilar, 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5116Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5118Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5119Injection, rituximab-pvvr, biosimilar, (RUXIENCE), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5120Injection, pegfilgrastim-bmez (ziextenzo), biosimilar, 0.5 mgNevada Prior Authorization List, Pg 167 Original policy
Q5121Injection, infliximab-axxq, biosimilar, (AVSOLA), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5122Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mgNevada Prior Authorization List, Pg 167 Original policy
Q5123Injection, rituximab-arrx, biosimilar, (riabni), 10 mNevada Prior Authorization List, Pg 167 Original policy
Q5124Injection, ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mgNevada Prior Authorization List, Pg 167 Original policy
Q5125Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgramNevada Prior Authorization List, Pg 167 Original policy
Q5126Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5127Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mgNevada Prior Authorization List, Pg 167 Original policy
Q5128Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mgNevada Prior Authorization List, Pg 167 Original policy
Q5129Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mgNevada Prior Authorization List, Pg 167 Original policy
Q5130Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mgNevada Prior Authorization List, Pg 167 Original policy
Q5131Injection, adalimumab-aacf (idacio), biosimilar, 20 mgNevada Prior Authorization List, Pg 168 Original policy
Q5132Injection, adalimumab-afzb (abrilada), biosimilar, 10 mgNevada Prior Authorization List, Pg 168 Original policy
Q5133Injection, tocilizumab-bavi (Tofidence), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5134Injection, natalizumab-sztn (Tyruko), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5135Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5136Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5137Injection, ustekinumab-auub (Wezlana), biosimilar, SC, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5138Injection, ustekinumab-auub (Wezlana), biosimilar, IV, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5140Injection, adalimumab-fkjp, biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5141Injection, adalimumab-aaty, biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5142Injection, adalimumab-ryvk biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5143Injection, adalimumab-adbm, biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5144Injection, adalimumab-aacf (idacio), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5145Injection, adalimumab-afzb (abrilada), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5146Injection, trastuzumab-strf (hercessi), biosimilar, 10 mgNevada Prior Authorization List, Pg 168 Original policy
Q5147Injection, aflibercept-ayyh (Pavblu), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5148Injection, filgrastim-txid (Nypozi), biosimilar, 1 mcgNevada Prior Authorization List, Pg 168 Original policy
Q5149Injection, aflibercept-abzv (Enzeevu), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5150Injection, aflibercept-mrbb (Ahzantive), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5151Injection, eculizumab-aagh (Epysqli), biosimilar, 2 mgNevada Prior Authorization List, Pg 168 Original policy
Q5152Injection, eculizumab-aeeb (Bkemv), biosimilar, 2 mgNevada Prior Authorization List, Pg 168 Original policy
Q5153Injection, aflibercept-yszy (opuviz), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5154Injection, omalizumab-igec (Omlyclo), biosimilar, 5 mgNevada Prior Authorization List, Pg 168 Original policy
Q5155Injection, aflibercept-jbvf (Yesafili), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy
Q5156Injection, tocilizumab-anoh (Avtozma), biosimilar, 1 mgNevada Prior Authorization List, Pg 168 Original policy

Sources

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