Anthem Blue Cross Blue Shield of California prior authorization code reference, page 68
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 |
|---|---|---|
| J3111 | Romosozumab-aqqg (Evenity) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3241 | Teprotumumab-trbw (Tepezza) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3245 | Tildrakizumab-asmn (Ilumya) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3247 | Secukinumab (Cosentyx) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3285 | Treprostinil (Remodulin) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3299 | Triamcinolone acetonide inj susp (Xipere) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3304 | Traiamcinolone Acetonide (Zilretta) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3316 | Triptorelin extended release (Triptodur) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3357 | Ustekinumab (Stelara) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3358 | Ustekinumab (Stelara) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3380 | Vedolizumab (Entyvio) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3385 | Velaglucerase alfa (VPRIV) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3397 | Vestronidase alfa (Mepsevii) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3401 | Beremagene geperpavec (Vyjuvek) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3404 | Zopapogene imadenovec-drba (Papzimeos) | California PPO Prior Authorization List, Pg 181 Original policy |
| J3489 | Injection, zoledronic acid, 1 mg (Reclast) | California PPO Prior Authorization List, Pg 181 Original policy |
| J7170 | Emicizumab-kxwh (Hemlibra) | California PPO Prior Authorization List, Pg 183 Original policy |
| J7171 | ADAMTS13, recombinant-krhn (Adzynma) | California PPO Prior Authorization List, Pg 183 Original policy |
| J7172 | Marstacimab-hncq (Hympvazi) | California PPO Prior Authorization List, Pg 183 Original policy |
| J7173 | Concizumab‑mtci (Alhemo) | California PPO Prior Authorization List, Pg 183 Original policy |
| J7174 | Fitusiran (Qfitlia) | California PPO Prior Authorization List, Pg 183 Original policy |
| J7175 | Factor X (Coagadex) | California PPO Prior Authorization List, Pg 183 Original policy |
| J7176 | Fibrinogen, human-chmt) (Fesilty) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7177 | Human fibrinogen (Fibryga) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7178 | Fibrinogen concentrate )RiaSTAP) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7179 | Von Willebrand Factor (Vonvendi) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7180 | Factor XIII concentrate (human) (Corifact) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7181 | Coagulation factor XIII A-subunit (recombinant) (Tretten) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7182 | Factor VIII (antihemophilic factor, recombinant) (Novoeight) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7183 | Antihemophilic factor VIII (Wilate) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7185 | Factor VIII (antihemophilic factor, recombinant) (Xyntha, Xyntha Solofuse) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7186 | Antihemophilic factor VIII (Alphanate) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7187 | Antihemophilic factor VIII (Humate-P) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7188 | Antihemophilic Factor VIII (Obizur) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7189 | Factor VIIa Recombinant (Novoseven RT) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7190 | (Factor VIII) human plasma-derived (Hemofil M) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7191 | Antihemophilic Factor VIII (Obizur) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7192 | Factor VIII (antihemophilic factor, recombinant) (Advate, Kogenate-FS) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7193 | Coagulation factor IX (human) (AlphaNine SD) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7194 | Factor IX Complex Human (Profilnine SD) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7195 | Factor IX Recombinant (Benefix) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7198 | Anti-inhibitor coagulant complex (FEIBA) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7200 | Factor IX Recombinant (Rixubis) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7201 | Factor IX, Fc fusion protein (recombinant) (Alprolix) | California PPO Prior Authorization List, Pg 184 Original policy |
| J7202 | Factor IX, albumin fusion protein, (recombinant) (Idelvion) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7203 | Factor IX, (antihemophilic factor, recombinant), glycopegylated (Rebinyn) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7204 | Factor VIII (antihemophilic factor (recombinant), glycopegylated-exei (Esperoct) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7205 | Factor VIII Fc fusion protein, (recombinant) (Eloctate) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7207 | Factor VIII, (anti-hemophilic factor, recombinant), pegylated (Adynovate) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7208 | Factor VIII, (antihemophilic factor, recombinant), pegylated- aucl ([Jivi) | California PPO Prior Authorization List, Pg 185 Original policy |