Anthem Blue Cross Blue Shield of California prior authorization code reference, page 67
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
| Code | Description | Source |
|---|---|---|
| J1552 | Immune globulin, IV, nonlyophilized (Alyglo) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1577 | Immune globulin intravenous, human-kthm (Qivigy) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1595 | Glatiramer acetate (Copaxone) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1602 | Golimumab (Simponi Aria) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1628 | Guselkumab (Tremfya) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1632 | Brexanolone (Zulresso) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1675 | Histrelin acetate (Supprelin LA, Vantas) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1743 | Idursulfase (Elaprase) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1744 | Icatibant (Firazyr, Sajazir) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1745 | Infliximab (Remicade) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1747 | Spesolimab-sbzo (Spevigo) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1748 | Infliximab-dyyb (Zymfentra) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1757 | Tividenofusp alfa-eknm) (Avlayah) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1786 | Imiglucerase (Cerezyme) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1809 | Fosdenopterin (Nulibry) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1818 | Pegzilarginase-nbln (Loargys) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1823 | Inebilizumab-cdon (Uplizna) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1826 | Interferon beta-1a (Avonex) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1830 | Interferon beta-1b (Betaseron) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1931 | Laronidase (Aldurazyme) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1950 | Leuprolide acetate (for depot suspension) (Lupron Depot-Ped) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1951 | Leuprolide acetate (Fensolvi) | California PPO Prior Authorization List, Pg 179 Original policy |
| J1954 | Leuprolide acetate (for depot suspension) (Lupron Depot) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2170 | Mecasermin (Increlex) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2182 | Mepolizumab (Nucala) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2267 | Mirikizumab-mrkz (Omvoh) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2278 | Ziconotide Intrathecal Infusion (Prialt) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2323 | Natalizumab (Tysabri) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2326 | Nusinersen (Spinraza) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2327 | Risankizumab-rzaa (Skyrizi) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2329 | Ublituximab (Briumvi) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2350 | Ocrelizumab (Ocrevus) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2351 | Ocrelizumab/hyaluronidase-ocsq (Ocrevus Zunovo) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2356 | Tezepelumab-ekko (Tezspire) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2357 | Omalizumab (Xolair) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2361 | Depemokimab-ulaa (Exdensur) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2502 | Pasireotide (Signifor LAR) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2507 | Pegloticase (Krystexxa) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2508 | Pegunigalsidase alfa-iwxj (Elfabrio) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2777 | Faricimab-svoa (Vabysmo) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2778 | Ranibizumab (Lucentis) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2781 | Pegcetacoplan (Syfovre) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2782 | Avacincaptad pegol (Izervay) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2786 | Reslizumab (Cinqair) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2793 | Rilonacept (Arcalyst) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2840 | Sebelipase alfa (Kanuma) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2941 | Somatropin (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Zomacton) | California PPO Prior Authorization List, Pg 180 Original policy |
| J2998 | Plasminogen, human-tvmh (Ryplazim) | California PPO Prior Authorization List, Pg 180 Original policy |
| J3032 | Eptinezumab (Vyepti) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3060 | Taliglucerase alfa (Elelyso) | California PPO Prior Authorization List, Pg 181 Original policy |