Anthem Blue Cross Blue Shield of Colorado prior authorization code reference, page 74

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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

Imported source codes and labels; verify the complete review requirements in the original document
Code	Description	Source
J9064	Injection, cabazitaxel (Sandoz), not therapeutically equivalent to J9043, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9118	Injection, calaspargase pegol-mknl, 10 units	Colorado Prior Authorization List, Pg 160 Original policy
J9119	Injection, cemiplimab-rwlc, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9144	Injection, daratumumab, 10 mg and hyaluronidase-fihj	Colorado Prior Authorization List, Pg 160 Original policy
J9145	Injection, daratumumab, 10 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9161	Injection, denileukin diftitox-cxdl, 1 mcg	Colorado Prior Authorization List, Pg 160 Original policy
J9173	Injection, durvalumab, 10 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9176	Injection, elotuzumab, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9177	Injection, enfortumab vedotin-ejfv, 0.25 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9179	Injection, eribulin mesylate, 0.1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9183	Gemcitabine intravesical system, 225 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9202	Goserelin Acetate Implant	Colorado Prior Authorization List, Pg 160 Original policy
J9203	Injection, gemtuzumab ozogamicin, 0.1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9207	Injection, ixabepilone, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9210	Injection, emapalumab-lzsg, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9216	Injection, interferon, gamma-1B, 3 million units	Colorado Prior Authorization List, Pg 160 Original policy
J9217	Leuprolide Acetate Suspnsion	Colorado Prior Authorization List, Pg 160 Original policy
J9223	Injection, lurbinectedin, 0.1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9226	Histrelin implant (supprelin LA), 50 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9227	Injection, isatuximab-irfc, 10 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9228	Injection, ipilimumab, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9229	Injection, inotuzumab ozogamicin, 0.1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9248	Injection, melphalan (Hepzato), 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9256	Injection, nipocalimab-aahu, 3 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9262	Injection, omacetaxine mepesuccinate, 0.01 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9264	Injection, paclitaxel protein-bound particles, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9266	Injection, pegaspargase, per single dose vial	Colorado Prior Authorization List, Pg 160 Original policy
J9269	Injection, tagraxofusp-erzs, 10 micrograms	Colorado Prior Authorization List, Pg 160 Original policy
J9271	Injection, pembrolizumab, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9272	Injection, dostarlimab-gxly, 10 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9273	Injection, tisotumab vedotin-tftv, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9274	Injection, tebentafusp-tebn, 1 microgram	Colorado Prior Authorization List, Pg 160 Original policy
J9275	Injection, cosibelimab-ipdl, 2 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9276	Injection, zanidatamab-hrii, 2 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9277	Injection, pembrolizumab, 1 mg and berahyaluronidase alfa-pmph	Colorado Prior Authorization List, Pg 160 Original policy
J9281	Mitomycin pyelocalyceal instillation, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9282	Mitomycin, intravesical instillation, 1 mg	Colorado Prior Authorization List, Pg 160 Original policy
J9286	Injection, glofitamab-gxbm, 2.5 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9289	Injection, nivolumab, 2 mg and hyaluronidase-nvhy	Colorado Prior Authorization List, Pg 161 Original policy
J9292	Injection, pemetrexed dipotassium, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9294	Injection, pemetrexed (Hospira), not therapeutically equivalent to J9305, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9296	Injection, pemetrexed (Accord), not therapeutically equivalent to J9305, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9297	Injection, pemetrexed (sandoz), not therapeutically equivalent to j9305, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9298	Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9299	Injection, nivolumab, 1 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9301	Injection, obinutuzumab, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9302	Injection, ofatumumab, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9303	Injection, panitumumab, 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9304	Injection, pemetrexed (pemfexy), 10 mg	Colorado Prior Authorization List, Pg 161 Original policy
J9305	Injection, pemetrexed, NOS,10 mg	Colorado Prior Authorization List, Pg 161 Original policy

Sources

Colorado Prior Authorization List