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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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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use