Q2054 prior authorization | Premera Blue Cross of Washington

Q2054, Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose These criteria do not imply or guarantee approval., is on the Premera Blue Cross of Washington prior authorization list. Not a coverage or referral decision.

Code: Q2054
Description: Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose These criteria do not imply or guarantee approval.
Source: Clinical Review by Code List PBCWA, Pg 772 Original policy

Premera Blue Cross of Washington prior authorization

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