CPT Codes Requiring Prior Authorization - Molina Healthcare
CPT Codes Requiring Prior Authorization - Molina Healthcare
CPT Codes Requiring Prior Authorization - Molina Healthcare
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Procedure<br />
Code<br />
<strong>CPT</strong> <strong>Codes</strong> <strong>Requiring</strong><br />
<strong>Prior</strong> <strong>Authorization</strong><br />
Service Description PA Required by POS<br />
J1566 Inj, Immune Globulin, IV, Lyophilized,<br />
500 mg<br />
All<br />
J1568 Inj. Imm glob Octagam IV 500mg All<br />
J1569 Inj. Imm glob Gammagard IV 500mg All<br />
J1572 Inj. Imm glob Flebogamma IV 500mg All<br />
J1599 Ivig non-lyophilized, NOS All<br />
J1620 Gonadorelin Hydrochloride, Per 100 Mcg All<br />
J1626 Granisetron Hydrochloride, 100 mcg All<br />
J1680 Human fibrinogen conc inj All<br />
J1740 Ibandronate sodium injection All<br />
J1743 Inj Idursulfase 1 mg All<br />
J1745 Infliximab injection 10 mg All<br />
J1785 Imiglucerase, Per Unit All<br />
J1826 Interferon Beta-1A inj All<br />
J1950 Leuprolide Acetate Per 3.75 Mg All<br />
J1956 Levofloxacin, 250 mg All<br />
J2323 Inj. Natalizumab 1 mg All<br />
J2353 Inj, Octreotide, Depot for IM inj, 1 mg All<br />
J2357 Omalizumab, 5 mg All<br />
J2425 Inj, Palifermin 50 mcg All<br />
J2469 Palonosetron hcl, 25 mcg All<br />
J2503 Inj, Pegaptanib Sodium 0.3 mg All<br />
J2504 Inj, Pegademase bovine 25 IU All<br />
J2562 Plerixafor injection All<br />
J2724 Inj. Protein C IV Hum 10iu All<br />
J2778 Inj. Ranibizumab 0.1mg All<br />
J2783 Inj, Rasburicase, 0.5 mg All<br />
J2796 Romiplostim injection All<br />
J2941 Somatropin inj, 1 mg All<br />
J3120 Testosterone Enanthate,Up To 100 Mg All<br />
J3130 Testosterone Enanthate,Up To 200 Mg All<br />
J3140 Testosterone,Aqueous,Up To 50 Mg All<br />
J3150 Testosterone Propionate, Up To 100Mg All<br />
J3315 Triptorelin Pamoate, 3.75 mg All<br />
J3385 Velaglucerase alfa All<br />
J3470 Hyaluronidase,Up To 150 Units All<br />
26994OH0812