Anthem Blue Cross Blue Shield of California prior authorization code reference, page 70
Check eligibility for free
No account required. Sign a BAA to see plan details, coordination of benefits and more
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 |
|---|---|---|
| Q5143 | Adalimumab-adbm (Cyltezo) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5134 | Natalizumab-sztn (Tyruko) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5144 | Adalimumab-aacf (Idacio) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5145 | Adalimumab-afzb (Abrilada) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5147 | Aflibercept-ayyh (Pavblu) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5149 | Aflibercept-abzv (Enzeevu) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5150 | Aflibercept-mrbb (Ahzantive) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5151 | Eculizumab-aagh (Epysqi) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5152 | Eculizumab-aeeb (Bkemv) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5153 | Aflibercept-yszy (Opuviz) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5154 | Omalizumab - igec (Omlyclo) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5155 | Aflibercept-jbvf (Yesafili) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5164 | Ustekinumab-hmny (Starjemza) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5168 | Ranibizumab-leyk (Nufymco) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q5170 | Aflibercept-boav (Eydenzelt) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q9996 | Ustekinumab-ttwe (Pyzchiva) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q9997 | Ustekinumab-ttwe (Pyzchiva IV) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q9998 | Ustekinumab-aekn (Selarsdi) | California PPO Prior Authorization List, Pg 187 Original policy |
| Q9999 | Ustekinumab-aauz (Otulfi) | California PPO Prior Authorization List, Pg 187 Original policy |
| S9560 | Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | California PPO Prior Authorization List, Pg 187 Original policy |
| J0565 | Bezlotoxumab (Zinplava) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0641 | Levoleucovorin (Fusilev) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0642 | Levoleucovorin (Khapzory) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0881 | Darbepoetin Alfa (Aranesp) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0882 | Darbepoetin Alfa (Aranesp) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0896 | Luspatercept (Reblozyl) | California PPO Prior Authorization List, Pg 188 Original policy |
| J0897 | Denosumab (Prolia, Xgeva) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1442 | Filgrastim (Neupogen) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1447 | Tbo-Filgrastim (Granix) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1449 | Eflapegrastim-xnst (Rolvedon) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1459 | Immune globulin, IV, non-lyophilized (Privigen) | California PPO Prior Authorization List, Pg 188 Original policy |
| J1551 | Immuno globulin (Cutaquig) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1553 | Immune globulin intravenous, human-dira (Yimmugo) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1554 | Immune Globulin (Human) IV (Asceniv) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1555 | Immune Globulin (Cuvitru) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1556 | Immune Globulin (Bivigam) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1557 | Immune Globulin (Gammaplex) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1558 | Immune Globulin (Human)-klhw (Xembify) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1559 | Immune Globulin (Human) Subcutaneous (Hizentra) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1561 | Immune Globulin (Human) IV or Subcutaneous (Gamunex- C/Gammaked) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1566 | Immune Globulin (Human) IV (Gammagard SD) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1568 | Immune Globulin (Human) IV (Octagam) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1569 | Immune Globulin (Gammagard Liquid, Gammagard Liquid ERC) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1572 | Immune Globulin (Human) IV (Flebogamma) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1575 | Immune Globulin (Human) IV (HyQvia) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1576 | Immune Globulin (Human) IV (Panzyga) | California PPO Prior Authorization List, Pg 189 Original policy |
| J1930 | Lanreotide (Somatuline Depot) | California PPO Prior Authorization List, Pg 190 Original policy |
| J1932 | Lanreotide (cipla) | California PPO Prior Authorization List, Pg 190 Original policy |
| J2353 | Octreotide, depot form (Sandostatin LAR depot) | California PPO Prior Authorization List, Pg 190 Original policy |
| J2354 | Octreotide (Sandostatin) | California PPO Prior Authorization List, Pg 190 Original policy |