Anthem Blue Cross Blue Shield of California prior authorization code reference, page 69
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 |
|---|---|---|
| J7209 | Factor VIII, (antihemophilic factor, recombinant) (Nuwiq) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7210 | Factor VIII, (Antihemophilic Factor, recombinant) (Afstyla) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7211 | Factor VIII, (antihemophilic factor, recombinant( (Kovaltry) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7212 | Factor VIIa Recombinant (SevenFact) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7213 | Factor IX (anti-hemophilic factor, recombinant) (Ixinity) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7214 | Antihemophilic factor (recombinant) (Altuviiio) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7311 | Fluocinolone acetonide, intravitreal implant (Retisert) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7312 | Dexamethasone intravitreal implant (Ozurdex) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7313 | Fluocinolone acetonide intravitreal implant (Iluvien) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7314 | Fluocinolone acetonide, intravitreal implant (Yutiq) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7340 | Carbidopa/levodopa enteral suspension (Duopa) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7351 | Bimatoprost, intracameral implant (Durysta) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7352 | Afamelanotide (Scenesse) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7353 | Anacaulase-bcdb (Nexobrid) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7354 | Cantharidin (Ycanth) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7355 | Travoprost Implant (iDoseTR) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7356 | Ffoscarbidopa (Vyalev) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7686 | Treprostinil (Tyvaso) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7799 | Pegcetacoplan (Empaveli) | California PPO Prior Authorization List, Pg 185 Original policy |
| J7999 | Compounded drug, not otherwise classified [when specified as implantable naltrexone pellets] | California PPO Prior Authorization List, Pg 185 Original policy |
| J8499 | Treprostinil (Yutrepia) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9202 | Goserelin acetate (Zoladex) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9210 | Emapalumab-lzsg (Gamifant) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9217 | Leuprolide acetate (for depot suspension) (Lupron Depot) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9218 | Leuprolide acetate (Lupron) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9226 | Histrelin acetate (Supprelin LA) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9256 | Nipocalimab (Imaavy) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9312 | Rituximab (Rituxan) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9332 | Efgartigimod alfa-fcab (Vyvgart) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9333 | Rozanolixizumab-noli (Rystiggo) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9334 | Efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9376 | Pozelimab-bbfg (Veopoz) | California PPO Prior Authorization List, Pg 186 Original policy |
| J9381 | Teplizumab-mzwv (Tzield) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q3027 | Interferon beta-1a (Avonex) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q3028 | Interferon beta-1a (Rebif) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q4074 | Iloprost (Ventavis) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5098 | Ustekinumab-srlf (Imuldosa) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5099 | Ustekinumab‑stba (Steqeyma) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5100 | Ustekinumab-kfce (Yesintek) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5103 | Infliximab-dyyb (Inflectra) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5104 | Infliximab-abda (Renflexis) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5121 | Infliximab-axxq (Avsola) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5123 | Rituximab-arrx (RIABNI) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5124 | Ranibizumab-nuna (Byooviz) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5128 | Ranibuzumab-cqrn (Cimerli) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5137 | Ustekinumab-auub (Wezlana) | California PPO Prior Authorization List, Pg 186 Original policy |
| Q5138 | Ustekinumab-auub (Wezlana) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5140 | Adalimumab-fkjp (Hulio) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5141 | Adalimumab-aaty (Yuflyma) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5142 | Adalimumab-ryvk (Simlandi) | California PPO Prior Authorization List, Pg 187 Original policy |