Specialty Solution Procedure Codes
PW_B125551
If you are a pharmacy provider, please follow the state of Indiana's pharmacy guidelines for Medicaid prior authorization.
If you are a nonpharmacy provider, and you have the following list of procedure codes, contact Anthem's Utilization Management department at 1-866-408-7187:
Procedure Codes Drug Name
J0205 INJECTION, ALGLUCERASE, PER 10
J0348 ANADULAFUNGIN INJECTION
J0364 APOMORPHINE HYDROCHLORIDE
J0894 DACOGEN 50MG INJ
J1430 ETHANOLAMINE OLEATE 100 MG
J1567 IMMUNE GLOBULIN, LIQUID
J1640 HEMIN, 1 MG
J1740 IBANDRONATE SODIUM INJECTION
J2940 INJECTION, SOMATREM
J3285 TREPROSTINIL INJECTION
J3396 VERTEPORFIN INJECTION
J3471 OVINE, UP TO 999 USP UNITS
J3472 OVINE, 1000 USP UNITS
J3490 (R) AMINOCAPR AC SYP 25%****
J9035 BEVACIZUMAB INJECTION
J9261 NELARABINE INJECTION
J9303 VECTIBIX INJ 100MG/5ML VIAL
J9303 VECTIBIX INJ 200MG/10ML VIAL
J9303 VECTIBIX INJ 400MG/20ML VIAL
Q2017 TENIPOSIDE, 50 MG
Q3025 IM INJ INTERFERON BETA 1-
Q4079 NATALIZUMAB INJECTION
Last Update: 12/28/2009 Version 5
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