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Anthem Blue Cross Blue Shield of Colorado prior authorization code reference, page 83

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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
CodeDescriptionSource
Q4359Choriply, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q4360Amchoplast fd, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q4361Epixpress, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q4362Cygnus disk, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q4363Amnio burgeon membrane and hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q4364Amnio burgeon xplus membrane and xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q4365Amnio burgeon dual-layer membrane, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q4366Dual layer amnio burgeon x-membrane, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q4367Amniocore sl, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q4369Amnioplast 3, per square centimeter (add-on, list separately in addition to primary procedure)Colorado Prior Authorization List, Pg 174 Original policy
Q5098Injection, ustekinumab-srlf (imuldosa), biosimilar, 1 mgColorado Prior Authorization List, Pg 174 Original policy
Q5099Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mgColorado Prior Authorization List, Pg 174 Original policy
Q5100Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mgColorado Prior Authorization List, Pg 174 Original policy
Q5101Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgramColorado Prior Authorization List, Pg 174 Original policy
Q5103Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5104Injection, infliximab-abda, biosimilar, (renflexis), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5105Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for ESRD on dialysis), 100 unitsColorado Prior Authorization List, Pg 174 Original policy
Q5106Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD use), 1000 unitsColorado Prior Authorization List, Pg 174 Original policy
Q5107Injection, bevacizumab-awwb, biosimilar, (Mvasi), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5108Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mgColorado Prior Authorization List, Pg 174 Original policy
Q5109Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5110Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgramColorado Prior Authorization List, Pg 174 Original policy
Q5111Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mgColorado Prior Authorization List, Pg 174 Original policy
Q5112Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5113Injection, trastuzumab-pkrb, biosimilar, (herzuma), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5114Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5115Injection, rituximab-abbs, biosimilar, 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5116Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5118Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5119Injection, rituximab-pvvr, biosimilar, (RUXIENCE), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5120Injection, pegfilgrastim-bmez (ziextenzo), biosimilar, 0.5 mgColorado Prior Authorization List, Pg 174 Original policy
Q5121Injection, infliximab-axxq, biosimilar, (AVSOLA), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5122Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mgColorado Prior Authorization List, Pg 174 Original policy
Q5123Injection, rituximab-arrx, biosimilar, (riabni), 10 mColorado Prior Authorization List, Pg 174 Original policy
Q5124Injection, ranibizumab-nuna, biosimilar, (Byooviz), 0.1 mgColorado Prior Authorization List, Pg 174 Original policy
Q5125Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgramColorado Prior Authorization List, Pg 174 Original policy
Q5126Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mgColorado Prior Authorization List, Pg 174 Original policy
Q5127Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mgColorado Prior Authorization List, Pg 175 Original policy
Q5128Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mgColorado Prior Authorization List, Pg 175 Original policy
Q5129Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mgColorado Prior Authorization List, Pg 175 Original policy
Q5130Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mgColorado Prior Authorization List, Pg 175 Original policy
Q5131Injection, adalimumab-aacf (idacio), biosimilar, 20 mgColorado Prior Authorization List, Pg 175 Original policy
Q5132Injection, adalimumab-afzb (abrilada), biosimilar, 10 mgColorado Prior Authorization List, Pg 175 Original policy
Q5133Injection, tocilizumab-bavi (Tofidence), biosimilar, 1 mgColorado Prior Authorization List, Pg 175 Original policy
Q5134Injection, natalizumab-sztn (Tyruko), biosimilar, 1 mgColorado Prior Authorization List, Pg 175 Original policy
Q5135Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mgColorado Prior Authorization List, Pg 175 Original policy
Q5136Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mgColorado Prior Authorization List, Pg 175 Original policy
Q5137Injection, ustekinumab-auub (Wezlana), biosimilar, SC, 1 mgColorado Prior Authorization List, Pg 175 Original policy
Q5138Injection, ustekinumab-auub (Wezlana), biosimilar, IV, 1 mgColorado Prior Authorization List, Pg 175 Original policy
Q5140Injection, adalimumab-fkjp, biosimilar, 1 mgColorado Prior Authorization List, Pg 175 Original policy

Sources

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