Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Policy Name/Program* Procedure Code (To serach, press Ctrl + F)

Abatacept (Orencia) J0129 Actigraphy 95803 Adalimumab (Humira®) J0135 Administrative - Unlisted Pharmacy J3490, J3590, J7699, J7799, J8499, J8999, J9999 Administrative-Medical - Air Ambulance* A0430 Administrative-Medical - Behavioral Health* 0362T, 0373T, 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90863, 90867, 90868, 90869, 90870, 90875, 90876, 90899, 96116, 96121, 96125, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 99499, G8539, G9012, H0001, H0008, H0009, H0010, H0011, H0012, H0013, H0014, H0015, H0020, H0031, H0032, H0035, H2012, H2014, H2019, H2020, H2034, S5108, S5110, S5111, S9480 Administrative-Medical - Bone Marrow 38204, 38205, 38206, 38207, 38230, 38240, 38241, Transplant* 38242, 86813, 86817 Administrative-Medical - Clinical Trials* S9988, S9990, S9991, S9992, S9994, S9996 Administrative-Medical - Continuous Home T2043 Hospice* Administrative-Medical - Dialysis* 90935, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90993, 90999 Administrative-Medical - Factor for the C9041, J7168, J7169, J7170, J7175, J7180, J7181, Treatment of Hemophilia* J7182, J7183, J7185, J7186, J7187, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7196, J7197, J7198, J7199, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211 Administrative-Medical - Heart Lung Transplant* 33935 Administrative-Medical - Heart Transplant* 33945 Administrative-Medical - Hemodialysis* 90937 Administrative-Medical - Home Hospice* Q5010, S9126, T2042 Administrative-Medical - Home Infusion* S9379 Administrative-Medical - Hospice Care (Assisted Q5002 Living Facility)* Administrative-Medical - Hospice Care (Hospice Q5006 Inpatient Facility)*

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Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Administrative-Medical - Hospice Care (Inpatient Q5005 Hospital)* Administrative-Medical - Hospice Care (Inpatient Q5008 Psych Facility)* Administrative-Medical - Hospice Care (Long- Q5007 Term Care Facility)* Administrative-Medical - Hospice Care (Skilled Q5004 Nursing Facility)* Administrative-Medical - Inpatient 96413, 96415, 96416, 96417, 96440, 96446, 96450, Injectable/Infusion* 96542, 96549 Administrative-Medical - Intestine/Bowel 44135, 44136 Transplant* Administrative-Medical - Liver Transplant* 47135 Administrative-Medical - Lung Transplant* 32852, 32854 Administrative-Medical - Nursing/Shift Care* S9123, S9124 Administrative-Medical - Pancreas Transplant* 48554 Administrative-Medical - Peritoneal Dialysis* 90945 Administrative-Medical - Solid Organ Transplant* Q0508, S9975 Administrative-Pharmacy S9560 Ado-Trastuzumab Emtansine (Kadcyla®) J9354 Afamelanotide (Scenesse) J7352 Aflibercept (Eylea®) J0178 Agalsidase Beta (Fabrazyme®) J0180 Aldesleukin (Proleukin, IL-2, Interleukin) J9015 Alemtuzumab Inj (LEMTRADA®) J0202 Alglucosidase Alfa (Lumizyme®) J0221 Ambulatory Event Monitors and Mobile Cardiac 33285, 93241, 93242, 93243, 93244, 93245, 93246, Outpatient Telemetry 93247, 93248, 93268, 93270, 93271, 93272 Anidulafungin (Eraxis) J0348 Apomorphine (Apokyn®) J0364 Aripiprazole Injection (Abilify Maintena) J0401 Aripiprazole Lauroxil Injection (Aristada®) J1944 Aripiprazole lauroxil (Aristada initio) J1943 Asparaginase Erwinia Chrysanthemi (Erwinaze) J9019 Assays of Genetic Expression in Tumor Tissue as a 81519, 81521, S3854 Technique to Determine Prognosis in Patients with Breast Cancer Atezolizumab (Tecentriq) J9022

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Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Auditory Brainstem Implant S2235 Autografts and Allografts in the Treatment of 27415, 27416, 29866, 29867 Focal Articular Cartilage Lesions Autologous Chondrocyte Implantation for Focal 27412, J7330, S2112 Articular Cartilage Lesions Avelumab (Bavencio) J9023 Axicabtagene Ciloleucel (Yescarta) 0537T, 0538T, 0539T, 0540T, Q2041 Azacitidine (Vidaza) J9025 Balloon Ostial Dilation for Treatment of Chronic 31295, 31296, 31297, 31298 and Recurrent Acute Rhinosinusitis Bariatric Surgery 43632, 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43850, 43855, 43860, 43865, 43886, 43887, 43888, 43999 Belantamab mafodontin-blmf (Blenrep) J9037 Belatacept (Nulojix) J0485 Belimumab (Benlysta®) J0490 Belinostat (Beleodaq™) J9032 Bendamustine (Belrapzo) J9036 Bendamustine (Bendeka) J9034 Bendamustine (Treanda®) J9033 Benralizumab (Fasenra) J0517 Bevacizumab (Avastin®) J9035 Bevacizumab-awwb (Mvasi) Q5107 Bevacizumab-bvzr (Zirabev) Q5118 Bezlotoxumab (Zinplava) J0565 Bimatoprost implant (Durysta) J7351 Bioengineered Skin and Soft Tissue Substitutes Q4100, Q4101, Q4102, Q4105, Q4106, Q4107, Q4116, Q4124, Q4128 Biofeedback as a Treatment of Urinary 90901, E0746 Incontinence in Adults Biventricular Pacemakers (Cardiac 33208, 33224 Resynchronization ) for the Treatment of Heart Failure Blepharoplasty, Blepharoptosis Repair (Levator 15820, 15821, 15822, 15823, 67900, 67901, 67902, Resection) and Brow Lift (Repair of Brow Ptosis) 67903, 67904, 67906, 67908, 67909 Blinotumomab (Blincyto®) J9039 Bortezomib (Velcade®) J9041, J9044

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Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Botulinum Toxin A AbobotulinumtoxinA J0586 (Dysport®) Botulinum Toxin A IncobotulinumtoxinA J0588 (Xeomin®) Botulinum Toxin B RimabotulinumtoxinB J0587 (Myobloc®) Botulinum Toxin Type A OnobotulinumtoxinA J0585 (Botox®) Breast Implant Management 19328, 19330, 19340, 19342, 19370, 19371, C1789, L8030, L8039, L8600 Brentuximab Vedotin (AdcetrisTM) J9042 Brexanolone (Zulresso) J1632 Brexucabtagene autoleucel (Tecartus) Q2053 Brolucizumab-dbll (Beovu) J0179 Buprenorphine Implant (Probuphine) J0570 Buprenorphine extended-release injection Q9991, Q9992 (Sublocade) Burosumab-twza (Crysvita) J0584 C1 Esterase Inhibitor (Berinert®, Cinryze®) J0597, J0598 C1 Esterase Inhibitor Recombinant (RUCONEST) J0596 C1 esterase inhibitor (Haegarda) J0599 Cabazitaxel (Jevtana ®) J9043 Cabotegravir and Rilpivirine (Cabenuva) C9077 Calaspargase pegol-mknl (Asparlas) J9118 Canakinumab (Ilaris®) J0638 Capsaicin 8% Patch (Qutenza®) J7336 Carfilzomib (Kyprolis®) J9047 (Amondys 45) C9075 Caspofungin (Cancidas®) J0637 Cellular Immunotherapy for Prostate Cancer Q2043 Cemiplimab-rwlc (Libtayo) J9119 Cerliponase alfa (Brineura) J0567 Certolizumab Pegol (Cimzia) J0717 Cetuximab (Erbitux®) J9055 Charged-Particle (Proton or Helium Ion) 77520, 77522, 77523, 77525 Radiotherapy for Neoplastic Conditions Clofarabine (Clolar) J9027 Collagenase Clostridium Histolyticum (Xiaflex®) J0775

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Blue Shield of California is an independent member of the Blue Shield Association

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Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Continuous Passive Motion in the Home Setting E0935, E0935, E0935, E0936, E0936, E0936 Copanlisib (Aliqopa) J9057 Corticotropin, Repository (H.P. Acthar® Gel) J0800 Crizanlizumab-tmca (Adakveo) C9053, J0791 Cryoablation of Tumors Located in the , 0581T, 19105, 20983, 50250, 50542, 50593 Lung, Breast, Pancreas, or Bone Dalbavancin (Dalvance™) J0875 Daratumumab (Darzalex) J9145 Daratumumab and hyaluronidase-fihj (Darzalex J9144 Flexpro) Darbepoetin Alfa (Aranesp®) J0881 Daunorubicin cytarabine liposome (Vyxeos) J9153 Decitabine (Dacogen) J0894 Degarelix (Firmagon®) J9155 Denosumab (Prolia™) J0897 Denosumab (Xgeva) J0897 Dental Anesthesia 00170 Dexamethasone Intravitreal Implant (Ozurdex®) J7312 Diagnosis and Medical Management of 95782, 95783, 95805, 95807, 95808, 95810, 95811, Obstructive Sleep Apnea Syndrome E0485, E0486, E0601 Dihydroergotamine Mesylate Injection (D.H.E. J1110 45®) Durvalumab (Imfinzi) J9173 Ecallantide (Kalbitor®) J1290 Eculizumab (Soliris®) J1300 Edaravone (Radicava) J1301 Elective Invasive Coronary Angiography (ICA) 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461 Elective Percutaneous Coronary Intervention 92920, 92921, 92924, 92925, 92928, 92929, 92933, (PCI) 92934, 92937, 92938, 92941, 92943, 92944, C1874, C9600, C9601, C9602, C9603, C9604, C9605, C9607, C9608 Elosulfase Alfa (Vimizim®) J1322 Elotuzumab (Empliciti®) J9176 Emapalumab-lzsg (Gamifant) J9210 Endoscopic Radiofrequency Ablation or 43229, 43270 Cryoablation for Barrett Esophagus

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Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Endovascular Procedures for Intracranial Arterial 61635 Disease (Atherosclerosis and Aneurysms) Enfortumab vedotin-ejfv (Padcev) J9177 Epoetin Alfa (Procrit®) J0885 Epoetin alfa-epbx (Retacrit) Q5106 Epoprostenol (Flolan® Veletri®) J1325 Eptinezumab-jjmr (Vyepti) J3032 Eribulin (Halaven) J9179 Esketamine nasal spray (Spravato) S0013 Esophageal pH Monitoring 91034, 91035, 91037, 91038 Etanercept (Enbrel®) J1438 (Exondys 51) J1428 Evinacumab-dgnb (Evkeeza) C9079 External Insulin Infusion Pump E0784 Extracorporeal Shock Wave Treatment for 0101T, 0102T, 28890 Plantar Fasciitis and Other Musculoskeletal Conditions Extracranial Carotid Artery Stenting 0075T, 0076T, 37215, 37216 Fam-trastuzumab deruxtecan-nxki (Enhertu) J9358 Filgrastim, G-CSF, (Neupogen®) J1442 Filgrastim-Sndz (Zarxio®) Q5101 Filgrastim-aafi (Nivestym) Q5110 Fluocinolone Intravitreal Implant (Iluvien®) J7313 Fluocinolone Intravitreal Implant (Retisert®) J7311 Fluocinolone intravitreal implant (Yutiq) J7314 Fremanezumab-vfrm (Ajovy) J3031 Fulvestrant (Faslodex®) J9395 Functional Neuromuscular Electrical Stimulation E0744, E0764, E0770 Galsulfase (Naglazyme®) J1458 Gemtuzumab Ozogamicin (Mylotarg) J9203

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Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 6 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Gender Reassignment Surgery 11920, 11921, 11922, 11950, 11951, 11952, 11954, 11960, 11970, 11971, 15770, 15775, 15776, 15777, 15824, 15825, 15826, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 19300, 19301, 19303, 19318, 19325, 19340, 19342, 19357, 21087, 21088, 21089, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 21270, 21299, 30400, 30410, 30420, 30430, 30435, 30450, 31587, 31599, 31750, 53410, 53430, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55150, 55175, 55180, 55970, 55980, 56620, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57295, 57296, 57335, 57426, 57530, 58150, 58180, 58260, 58262, 58263, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58555, 58570, 58571, 58572, 58573, 58661, 58720, 58940, 92507, 92508, C1813, C2622 Gene Expression Profile Testing and Circulating 84999 Tumor DNA Testing for Predicting Recurrence in Colon Cancer Gene Variants Associated With Breast Cancer in 81406 Individuals at High Breast Cancer Risk Genetic Testing for BRCA1 or BRCA2 for 81162, 81163, 81164, 81165, 81166, 81167, 81212, Hereditary Breast/Ovarian Cancer Syndrome 81215, 81216, 81217, 81479 and Other High-Risk Cancers Genetic Testing for Cardiac Ion 81413, 81414 Channelopathies Genetic Testing for Developmental 81228, 81229, S3870 Delay/Intellectual Disability, Autism Spectrum Disorder, and Congenital Anomalies Genetic Testing for Inherited Thrombophilia 81240, 81241, 81291 Genetic Testing for Lynch Syndrome and Other 81201, 81202, 81203, 81210, 81292, 81293, 81294, Inherited Colon Cancer Syndromes 81295, 81296, 81297, 81298, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81403, 81406 Genetic Testing for Mitochondrial Disorders 81460, 81465 Genetic Testing for Predisposition to Inherited 81406, 81479 Hypertrophic Cardiomyopathy

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Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 7 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Genetic and Protein Biomarkers for the Diagnosis 81479, 81599 and Cancer Risk Assessment of Prostate Cancer Givosiran (Givlaari) C9056, J0223 Golimumab (Simponi Aria®) J1602 (Vyondys 53) J1429 Growth Hormone (GH) in Adults and J2941 Children,Somatropin Products:(Humatrope®, Nutropin®/NutropinAQ®, Genotropin®, Norditropin®, Saizen®, Tev-Tropin®, Omnitrope®) Guselkumab (Tremfya) J1628 Histrelin Implant (Supprelin LA®) J9226 Histrelin Implant (Vantas™) J9225 Hyaluronan (Synojoynt) J7331 Hyaluronan (Triluron) J7332 (Euflexxa®) J7323 Hyaluronic Acid (Gel One®) J7326 Hyaluronic Acid (GelSyn-3®) J7328 Hyaluronic Acid (GenVisc®) J7320 Hyaluronic Acid (Hyalgan® Supartz®) J7321 Hyaluronic Acid (Hymovis) J7322 Hyaluronic Acid (Monovisc®) J7327 Hyaluronic Acid (Orthovisc®) J7324 Hyaluronic Acid (Synvisc®, Synvisc One®) J7325 Hyaluronic acid (Trivisc) J7329 Hydroxyprogesterone Caproate (Makena) J1726 Hydroxyprogesterone Caproate, not otherwise J1729 specified (generic for Makena) Hyperbaric Oxygen Therapy 99183, A4575, E0446, G0277 Hysterectomy Surgery for Benign Conditions 51925, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58953, 58954, 58956, 59525 IV Antibiotics for Tickborne J0456, J0558, J0561, J0696, J0698, J1956, J2540 Ibalizumab-uiyk (Trogarzo) J1746 Ibritumomab (Zevalin) A9542, A9543 Icatibant (Firazyr®) J1744

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Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 8 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Idursulfase (Elaprase®) J1743 Iloprost inhalation (Ventavis®) Q4074 Imiglucerase (Cerezyme®) J1786 Immune Globulin, Intravenous IVIG 90291, J0850, J1459, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599 Immune Globulin, Subcutaneous J1558, J1559, J1575 Implantable Cardioverter Defibrillators 33216, 33217, 33230, 33231, 33240, 33249, 33262, 33263, 33264, 93287, C1721, C1722, C1777, C1882, C1895, C1896, G0448 Inebilizumab-cdon (Uplizna) J1823 Infliximab J1745, Q5121 Infliximab-abda, biosimilar (Renflexis) Q5104 Infliximab-dyyb (Inflectra) Q5103 Injectable Bulking Agents for the Treatment of 51715, L8603, L8606 Urinary and Fecal Incontinence Inotuzumab ozogamicin (Besponsa) J9229 Intensity-Modulated Radiotherapy of the Breast 77385, 77386, G6015, G6016 and Lung Intensity-Modulated Radiotherapy of the 77385, 77386, G6015, G6016 Prostate Intensity-Modulated Radiotherapy: Abdomen 77385, 77386, G6015, G6016 and Pelvis Intensity-Modulated Radiotherapy: Cancer of 77385, 77386, G6015, G6016 the Head and Neck or Thyroid Intensity-Modulated Radiotherapy: Central 77385, 77386, G6015, G6016 Nervous System Tumors Interferon Alfa 2b (Intron A®) J9214 Interferon Alfa-n3 (Alferon N®) J9215 Interferon Gamma-1b (Actimmune®) J9216 Intracavitary Balloon Catheter Brain 77761, 77762, 77763, 77770, 77771, 77772 Brachytherapy for Malignant Gliomas or Metastasis to the Brain Intraoperative Radiotherapy 77424, 77425, 77469 Iobenguane I-131 (Azedra) A9590 Ipilimumab (Yervoy) J9228 Irinotecan Liposome Injection (Onivyde®) J9205 Isatuximab-irfc (Sarclisa) J9227 Isavuconazonium (Cresemba®) J1833

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Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 9 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Ixabepilone (Ixempra®) J9207 JAK2, MPL, and CALR Testing for 81219, 81270, 81279, 81338, 81339 Myeloproliferative Neoplasms Knee Arthroplasty for Adults 27447 Knee Arthroscopy in Knee Osteoarthritis 29880, 29881 Knee Braces (Custom) L1840, L1844, L1846 Lanadelumab-flyo (Takhzyro) J0593 Lanreotide (Somatuline®) J1930 Laronidase (Aldurazyme®) J1931 Leuprolide acetate (Fensolvi) J1951 Levoleucovorin (Khapzory) J0642 Levoleucovorin Inj (Fusilev®) J0641 Lisocabtagene maraleucel (Breyanzi) C9076 Lumasiran (Oxlumo) J0224 Lumbar Spine Surgery 0163T, 0164T, 0165T Lurbinectedin (Zepzelca) J9223 Luspatercept-aamt (Reblozyl) J0896 Lutetium Lu 177 dotatate (Lutathera) A9513 Magnetoencephalography/Magnetic Source 95965, 95966, 95967, S8035 Imaging Margetuximab-cmkb (Margenza) J9353 Measurement of Lipoprotein-Associated 0052U, 83698 Phospholipase A2 in the Assessment of Cardiovascular Risk Mecasermin (Increlex®) J2170 Melphalan flufenamide hydrochloride (Pepaxto) C9080 Mepolizumab (Nucala®) J2182 Methoxy Polyethylene Glycol-Epoetin Beta J0888 (Mircera®) Methylnaltrexone (Relistor®) J2212 Micafungin (Mycamine®) J2248 Microprocessor-Controlled Prostheses for the L5856, L5857, L5858, L5859, L5973 Lower Limb Microwave and Locoregional Laser Tumor 47370, 47380, 47382 Ablation Mogamulizumab-kpkc (Poteligeo) J9204 Moxetumomab pasudotox-tdfk (Lumoxiti) J9313

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Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 10 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Multiple Sclerosis Therapy Glatiramer J1595 (Copaxone®) Multiple Sclerosis Drug Therapy Interferon beta J1826 1A (Avonex®) Multiple Sclerosis Drug Therapy interferon beta J1830 1B (Betaseron, Extavia) Myoelectric Prosthetic and Orthotic L8701, L8702 Components for the Upper Limb NIA /Spine 0095T, 0098T, 0200T, 0201T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0274T, 0275T, 22526, 22527, 22533, 22548, 22551, 22552, 22554, 22558, 22585, 22586, 22590, 22595, 22600, 22612, 22614, 22630, 22632, 22633, 22634, 22856, 22857, 22858, 22861, 22862, 22864, 22865, 27096, 62263, 62264, 62287, 62320, 62321, 62322, 62323, 62380, 63001, 63005, 63012, 63015, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63047, 63050, 63051, 63056, 63057, 63075, 63076, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, G0260, M0076, S2348 NIA Radiology 0042T, 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 75571, 75635, 76380, 76390, 77011, 77012, 77013, 77021, 77022, 77046, 77047, 77048, 77049, 77084, 78434, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, C8903,

blueshieldca.com 601 12th Street | Oakland, CA 94607

Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 11 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

C8905, C8906, C8908, C8937, G0235, G0252, S8037, S8085, S8092 Natalizumab (Tysabri®) J2323 Naxitamab-gqgk (Danyelza) J9348 Necitumumab (Portrazza) J9295 Negative Pressure Wound Therapy in the 97605, 97606, A6550, A9272, E2402, K0743, Outpatient Setting K0744, K0745, K0746 Nivolumab (Opdivo®) J9299 Noninvasive Prenatal Screening for Fetal 0168U Aneuploidies, Microdeletions, and Twin Zygosity Using Cell-Free Fetal DNA Noninvasive Techniques for the Evaluation and 83883 Monitoring of Patients With Chronic Liver Disease Nonpharmacologic Treatment of Rosacea 30117 Novel Biomarkers in Risk Assessment and 82172, 82610, 82664, 83695, 83700, 83701, 83704, Management of Cardiovascular Disease 85384, 85385 (Spinraza) J2326 Obinutuzumab (Gazyva®) J9301 Ocrelizumab (Ocrevus) J2350 Ocriplasmin (Jetrea®) J7316 Octreotide (Sandostatin® SC/IV) J2354 Octreotide IM Injection (Sandostatin LAR J2353 Depot®) Ofatumumab (Arzerra®) J9302 Olanzapine Long-Acting Injection (Zyprexa® J2358 RelprevvTM) Olaratumab (Lartruvo) J9285 Omacetaxine (Synribo) J9262 Omalizumab (Xolair®) J2357 -xioi (Zolgensma) J3399 Oritavancin (Orbactiv™) J2407 Orthognathic Surgery 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21247, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7995, D7996 Orthopedic Applications of Platelet-Rich Plasma 0232T

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Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 12 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Paclitaxel Protein Bound Suspension J9264 (Abraxane®) Palifermin (Kepivance®) J2425 Paliperidone (Invega Sustenna®, Invega Trinza®) J2426 Palivizumab (Synagis®) 90378 Panitumumab (Vectibix®) J9303 Panniculectomy, Abdominoplasty, and Surgical 15830, 15847 Management of Diastasis Recti Partial Thickness Rotator Cuff Tears and 29826, 29827 Acromioplasty/Subacromial Decompression Pasireotide Diaspartate (Signifor®, Signifor LAR®) J2502 Patisiran (Onpattro) J0222 Pegaptanib (Macugen®) J2503 Pegfilgrastim (Neulasta®) J2505 Pegfilgrastim-apgf (Nyvepria) Q5122 Pegfilgrastim-bmez (Ziextenzo) C9058, Q5120 Pegfilgrastim-cbqv (Udenyca) Q5111 Pegfilgrastim-jmdb (Fulphila) Q5108 Pegloticase (Krystexxa) J2507 Pelvic Floor Stimulation as a Treatment of Urinary E0740 and Fecal Incontinence Pembrolizumab (Keytruda®) J9271 Pemetrexed J9304, J9305 Peramivir (Rapivab™) J2547 Pertuzumab (Perjeta®) J9306 Pertuzumab, Trastuzumab, and Hyaluronidase- J9316 zzxf (Phesgo) Plerixafor (Mozobil®) J2562 Pneumatic Compression Pumps for Treatment of E0650, E0651, E0652, E0656, E0657, E0670 Lymphedema and Venous Ulcers Polatuzumab vedotin-piiq (Polivy) J9309 Power Wheelchairs and Power Operated E1016, E1018, E2300, E2301, E2310, E2311, E2351, Vehicles for Permanent Use E2358, E2360, E2362, E2364, E2367, E2372, E2609, E2610, E2617, K0669, K0806, K0807, K0808, K0830, K0831, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886 Pralatrexate (Folotyn) J9307 Protein C Concentrate (human) (Ceprotin®) J2724

blueshieldca.com 601 12th Street | Oakland, CA 94607

Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 13 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Radioembolization for Primary and Metastatic 37243, 75894, 77399, 77778, 79445, C2616, S2095 Tumors of the Liver Radiofrequency Ablation of Primary or 47370, 47380, 47382 Metastatic Liver Tumors Radium Ra 223 dichloride (Xofigo) A9606 Ramucirumab (Cyramza®) J9308 Ranibizumab (Lucentis®) J2778 Ravulizumab-cwvz (Ultomiris) J1303 Reconstructive Services 11950, 11951, 11952, 11954, 15770, 15775, 15776, 15777, 15824, 15825, 15826, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 19325, 19350, 19355, 19357, 19370, 21087, 21088, 21089, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 21270, 21299, 30400, 30410, 30420, 30430, 30435, 30450, 31587, 31599, 31750, 57335, 92507, 92508 Reduction Mammaplasty 19318 Reslizumab (Cinqair) J2786 Rilonacept (Arcalyst®) J2793 Risperidone Long-acting Injection (Risperdal J2794 Consta®) Risperidone extended-release (Perseris) J2798 Rituxan hyaluronidase (Rituxan Hycela) J9311 Rituximab J9312, Q5119, Q5123 Rituximab-abbs (Truxima) Q5115 Romidepsin C9065, J9315 Romiplostim (Nplate™) J2796 Romosozumab-aqqg (Evenity) J3111 Sacituzumab govitecan-hziy (Trodelvy) J9317 Sargramostim, GM-CSF (Leukine®) J2820 Sebelipase (Kanuma®) J2840 Semi-Implantable and Fully Implantable Middle S2230, V5095 Ear Hearing Aids Siltuximab (Sylvant™) J2860 Sodium hyaluronate (Durolane) J7318 Subcutaneous Immune Globulin (Cuvitru) J1555 Subtalar Arthroereisis 28725, 28735

blueshieldca.com 601 12th Street | Oakland, CA 94607

Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 14 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Sumatriptan Injection (Imitrex) J3030 Surgical Deactivation of Trigger Sites 15824, 15826, 30130, 30140, 30520, 64716, 67900 Surgical Treatment of Femoroacetabular 29914, 29915, 29916 Impingement Surgical Treatment of Gynecomastia 19300 Surgical Treatment of Snoring and Obstructive 21685, 41512, 41530, 42145, 42299 Sleep Apnea Syndrome Tafasitamab-cxix (Monjuvi) J9349 Tagraxofusp-erzs (Elzonris) J9269 Taliglucerase alfa (Elelyso®) J3060 Talimogene Laherparepvec (Imlygic) J9325 Tbo-Filgrastim (Granix®) J1447 Temsirolimus (Torisel®) J9330 Teprotumumab-trbw (Tepezza) J3241 Teriparatide (Forteo®) J3110 Testopel (testosterone pellet) S0189 Testosterone undecanoate (Aveed®) J3145 Tildrakizumab-asmn (Ilumya) J3245 Tisagenlecleucel (Kymriah) Q2042 Tocilizumab (Actemra®) J3262 Total Artificial Hearts and Implantable Ventricular 33927, 33928, 33929 Assist Devices Total Hip Arthroplasty for Adults 27130 Trabectedin (Yondelis®) J9352 Transcranial Magnetic Stimulation as a 90867, 90868, 90869 Treatment of Depression and Other Psychiatric/Neurologic Disorders Trastuzumab (Herceptin®) J9355 Trastuzumab hyaluronidase-oysk (Herceptin J9356 hylecta) Trastuzumab-anns (kanjinti) Q5117 Trastuzumab-dkst (Ogivri) Q5114 Trastuzumab-dttb (Ontruzant) Q5112 Trastuzumab-pkrb (Herzuma) Q5113 Trastuzumab-qyyp (Trazimera) Q5116 Treatment of Hyperhidrosis 32664

blueshieldca.com 601 12th Street | Oakland, CA 94607

Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 15 of 16

Prior Authorization List* for Blue Shield and FEP Members Effective September 1, 2021 (*This list is updated monthly)

Treatment of Varicose Veins/Venous 36465, 36466, 36468, 36470, 36471, 36475, 36476, Insufficiency 36478, 36479, 36482, 36483, 37500, 37765, 37766, S2202 Treprostinil IV (Remodulin®) J3285 Treprostinil inhalation (Tyvaso®) J7686 Trilaciclib (Cosela) C9078 Triptorelin (Triptodur) J3316 Ustekinumab Subcutaneous (Stelara) J3357 Ustekinumab intravenous (Stelara) J3358 Vedolizumab (Entyvio®) J3380 Velaglucerase alfa (VPRIV™) J3385 Vestronidase alfa-vjbk (Mepsevii) J3397 (Viltepso) J1427 Vincristine liposome (Marqibo®) J9371 Voretigene neparvovec-rzyl (Luxturna) J3398 Wearable Cardioverter Defibrillators 93292, 93745, K0606, K0607, K0608, K0609 Whole Exome and Whole Genome Sequencing 81415, 81416 for Diagnosis of Genetic Disorders Whole Gland Cryoablation of Prostate Cancer 55873 Wireless Capsule Endoscopy to Diagnose 91110, 91111 Disorders of the Small Bowel, Esophagus, and Colon Ziconotide (Prialt®) J2278 ZivAflibercept (Zaltrap®) J9400

blueshieldca.com 601 12th Street | Oakland, CA 94607

Blue Shield of California is an independent member of the Blue Shield Association

September 1, 2021 Page 16 of 16