A2004 prior authorization | Anthem Blue Cross and Blue Shield Virginia

A2004, Xcellistem, 1 mg/Original description: Miscellaneous with Motor <27.85, without comorbidities,10/2019 description: Miscellaneous M <46.50 and A >=77.50.,witho, is on the Anthem Blue Cross and Blue Shield Virginia HMO/EPO prior authorization list. Not a coverage or referral decision.

Code: A2004
Description: Xcellistem, 1 mg/Original description: Miscellaneous with Motor <27.85, without comorbidities,10/2019 description: Miscellaneous M <46.50 and A >=77.50.,witho
Source: Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 60 Original policy

Anthem Blue Cross and Blue Shield Virginia prior authorization

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