J1572 prior authorization | Anthem Blue Cross and Blue Shield New Hampshire

J1572, Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg, is on the Anthem Blue Cross and Blue Shield New Hampshire prior authorization list. Not a coverage or referral decision.

Code: J1572
Description: Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., liquid), 500 mg
Source: New Hampshire Precertification List, Pg 238 Original policy

Anthem Blue Cross and Blue Shield New Hampshire prior authorization

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