Anthem Blue Cross Blue Shield of California prior authorization code reference, page 71
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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 |
|---|---|---|
| J2506 | Pegfilgrastim (Neulasta, Neulasta Onpro) - excludes biosimilar | California PPO Prior Authorization List, Pg 190 Original policy |
| J2820 | Sargramostim (Leukine) | California PPO Prior Authorization List, Pg 190 Original policy |
| J3262 | Tocilizumab (Actemra) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9033 | Bendamustine HCL (Treanda) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9034 | Bendamustine (Bendeka) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9035 | Avastin (bevacizumab) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9036 | Bendamustine (Belrapzo) | California PPO Prior Authorization List, Pg 190 Original policy |
| J9301 | Obinutuzumab (Gazyva) | California PPO Prior Authorization List, Pg 190 Original policy |
| Q4081 | Epoetin alfa (for ESRD on dialysis) (Epogen, Procrit) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5101 | Filgrastim-sndz (Zarxio) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5105 | Epoetin alfa-epbx (Retacrit) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5106 | Epoetin alfa-epbx (Retacrit) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5108 | Pegfilgrastim-jmdb (Fulphila) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5110 | Filgrastim-aafi (Nivestym) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5111 | Pegfilgrastim-cbqv (Udenyca/Udenyca Onbody) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5115 | Tituximab-abbs (Truxima) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5119 | Rituximab-pvvr (Ruxience) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5120 | Pegfilgrastim-bmez, biosimilar (Ziextenzo) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5122 | Immune globulin (Nyvepria) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5125 | Filgrastim-ayow (Releuko) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5126 | Bevacizumab-maly (Alymsys) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5127 | Pegfilgrastim-fpgk (Stimufend) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5129 | Bevacizumab-adcd (Vegzelma) | California PPO Prior Authorization List, Pg 191 Original policy |
| Q5130 | Pegfilgrastim-pbbk (Fylnetra) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5133 | Tocilizumab-bavi (Tofidence) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5135 | Tocilizumab-aazg (Tyenne) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5136 | Denosumab-bbdz (Jubbonti) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5148 | Filgrastim-txid (Nypozi) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5156 | Tocilizumab-anoh (Avtozma) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5157 | Denosumab-bmwo (Osenvelt, Stoboclo) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5158 | Denosumab-bnht (Bomyntra, Conexxence) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5159 | Denosumab-dssb (Ospomyv, Xbryk) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5161 | Denosumab-kyqq (Aukelso, Bosaya) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5162 | Denosumab-nxxp (Bildyos, Bilprevda) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5166 | Denosumab-desu (Jubereq, Osvytri) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5167 | Denosumab-qbde (Enoby, Xtrenbo) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5169 | Pegfilgrastim-unne (Armlupeg) | California PPO Prior Authorization List, Pg 192 Original policy |
| Q5171 | Denosumab-mobz (Boncresa) | California PPO Prior Authorization List, Pg 193 Original policy |
| Q5172 | Filgrastim-laha (Filkri) | California PPO Prior Authorization List, Pg 193 Original policy |
| Q5173 | Denosumab-adet (Ponlimsi) | California PPO Prior Authorization List, Pg 193 Original policy |