outpatient prior authorization requirements€¦ · outpatient prior authorization requirements ....
TRANSCRIPT
HealthKeepers, Inc. is a health plan that contracts with both Medicare and the Virginia Department of Medical Assistance Services to provide benefits of both programs to enrollees. HealthKeepers, Inc. is an independent licensee 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.
PF-AVA-0374-14 April 2014
Outpatient Prior Authorization Requirements
This document provides the services requiring prior authorization. This list is for services provided to Anthem HealthKeepers Medicare-Medicaid Plan (MMP) members only.
Exclusions:
Behavioral health
Pharmacy
The following always require prior authorization:
Out-of-network/out-of-area services
DME rentals
Inpatient services
Fixed-wing transportation
Pain management
Transplant services
All services billed with the following revenue codes:
o 0023 – Home health prospective payment system
o 0240-0249 – All-inclusive ancillary psychiatric
o 0570-0572, 0579 – Home health aide
o 0632 – Pharmacy, multiple sources
o 0901, 0905-0907, 0913, 0917 – Behavioral health treatment services
o 0944-0945 – Other therapeutic services
o 0961 – Psychiatric professional fees
o 3101-3109 – Adult day and foster care
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 2
0195T 15830 21127 21240 26561 37722
0196T 15847 21137 21242 26562 37735
0213T 17360 21138 21243 29800 37760
0214T 19300 21139 21244 29804 37761
0215T 19316 21141 21245 30120 37765
0216T 19318 21142 21246 30130 37766
0217T 19324 21143 21247 30140 37780
0218T 19325 21145 21248 30400 37785
0228T 19328 21146 21249 30410 38204
0229T 19330 21147 21255 30420 38205
0230T 19340 21150 21270 30430 38206
0231T 19342 21151 21275 30435 38207
0266T 19350 21154 21280 30450 38208
0267T 19357 21155 21282 30460 38209
0268T 19361 21159 21295 30462 38210
0269T 19364 21160 21296 30465 38211
0270T 19366 21172 21742 30520 38212
0271T 19367 21175 21743 30540 38213
0272T 19368 21179 22206 30545 38214
0273T 19369 21180 22207 30620 38215
0282T 19370 21181 22208 30630 38230
0283T 19371 21182 22533 30801 38232
0284T 19380 21183 22534 32851 38240
0308T 19396 21184 22548 32852 38241
0309T 21010 21188 22551 32853 38242
11920 21029 21193 22552 32854 38243
11921 21030 21194 22554 33935 42820
11922 21031 21195 22556 33945 42821
11950 21032 21196 22612 36468 42825
11951 21050 21198 22630 36470 42826
11952 21060 21199 22856 36471 42830
11954 21070 21206 22857 36475 42831
15781 21110 21208 22861 36476 42835
15820 21121 21209 22862 36478 42836
15821 21122 21210 22864 36479 43200
15822 21123 21215 22865 37700 43201
15823 21125 21235 26560 37718 43202
Anthem HealthKeepers Medicare-Medicaid Plan (MMPOutpatient Services Requiring Prior Authorizatio
April 201
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Page 3
43204 43773 62369 64490 67917 70551
43205 43774 62370 64491 67921 70552
43206 43775 63650 64492 67922 70553
43215 43842 63655 64493 67923 70554
43216 43843 63661 64494 67924 70555
43217 43845 63662 64495 67950 70557
43220 43846 63663 64550 69300 70558
43226 43847 63664 64553 69714 70559
43227 43848 63685 64555 69715 71250
43231 43886 63688 64561 69717 71260
43232 43887 64400 64565 69718 71270
43235 43888 64402 64568 69930 71275
43236 44137 64405 64569 70010 71550
43237 47135 64408 64570 70336 71551
43238 47136 64410 64575 70450 71552
43239 48554 64412 64580 70460 71555
43240 50320 64413 64581 70470 72125
43241 50340 64415 64585 70480 72126
43242 50360 64416 64590 70481 72127
43243 50365 64417 64595 70482 72128
43244 50380 64418 64611 70486 72129
43245 62264 64420 64612 70487 72130
43246 62280 64421 64615 70488 72131
43247 62281 64425 65756 70490 72132
43248 62282 64430 65757 70491 72133
43249 62292 64435 67900 70492 72141
43250 62310 64445 67901 70496 72142
43251 62311 64446 67902 70498 72146
43252 62318 64447 67903 70540 72147
43255 62319 64448 67904 70542 72148
43257 62350 64449 67906 70543 72149
43259 62351 64450 67908 70544 72156
43644 62360 64455 67909 70545 72157
43645 62361 64479 67911 70546 72158
43770 62362 64480 67914 70547 72159
43771 62367 64483 67915 70548 72191
43772 62368 64484 67916 70549 72192
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 4
72193 74182 78609 95827 97530 A7025
72194 74183 78811 95951 97532 A9274
72195 74185 78812 95953 97533 A9276
72196 75557 78813 95980 97537 A9277
72197 75559 78814 95981 97542 A9278
72198 75561 78815 95982 97602 A9901
73200 75563 78816 96101 97605 B9000
73201 75565 90283 96102 97606 B9002
73202 75571 90378 96103 97750 B9004
73206 75572 90867 96116 97755 B9006
73218 75573 90868 96118 97760 C1300
73219 75574 91111 96119 97761 C8931
73220 75635 92507 96120 98940 C8932
73221 76380 92508 96125 98941 C8933
73222 76390 92597 97002 98942 C8934
73223 77058 92601 97004 99183 C8935
73225 77059 92602 97010 99377 C8936
73700 77078 92603 97012 99477 C9257
73701 77084 92604 97016 99500 C9275
73702 78451 92626 97018 99501 C9734
73706 78452 92627 97022 99502 C9800
73718 78453 92630 97024 99503 E0100
73719 78454 92633 97026 99504 E0105
73720 78459 93797 97028 99505 E0110
73721 78466 93798 97032 99506 E0111
73722 78468 94660 97033 99507 E0112
73723 78469 94662 97034 99509 E0113
73725 78472 95782 97035 99510 E0114
74150 78473 95783 97036 99511 E0116
74160 78481 95800 97039 99512 E0130
74170 78483 95801 97110 99600 E0135
74174 78491 95805 97112 99601 E0140
74175 78492 95806 97113 99602 E0141
74176 78494 95807 97116 A0435 E0143
74177 78496 95808 97124 A4613 E0144
74178 78607 95810 97140 A5513 E0147
74181 78608 95811 97150 A7020 E0148
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 5
E0472 E0629 E0745 E0149 E0203 E0302
E0153 E0205 E0303 E0480 E0630 E0747
E0154 E0210 E0304 E0482 E0635 E0748
E0155 E0215 E0305 E0483 E0636 E0749
E0156 E0217 E0310 E0484 E0637 E0755
E0157 E0225 E0315 E0485 E0638 E0760
E0158 E0235 E0316 E0486 E0639 E0762
E0159 E0236 E0325 E0500 E0640 E0764
E0160 E0239 E0326 E0550 E0641 E0765
E0161 E0242 E0350 E0555 E0642 E0769
E0162 E0243 E0352 E0560 E0650 E0770
E0163 E0244 E0370 E0561 E0651 E0776
E0165 E0245 E0371 E0562 E0652 E0779
E0167 E0246 E0372 E0565 E0655 E0780
E0168 E0249 E0373 E0570 E0660 E0781
E0170 E0250 E0424 E0572 E0665 E0782
E0171 E0251 E0425 E0574 E0666 E0783
E0172 E0255 E0431 E0575 E0667 E0784
E0175 E0256 E0433 E0580 E0668 E0785
E0181 E0260 E0434 E0585 E0669 E0786
E0182 E0261 E0439 E0600 E0671 E0791
E0184 E0265 E0441 E0601 E0672 E0830
E0185 E0266 E0442 E0602 E0673 E0840
E0186 E0271 E0443 E0603 E0675 E0849
E0187 E0272 E0444 E0604 E0676 E0850
E0188 E0275 E0445 E0605 E0691 E0855
E0189 E0276 E0450 E0606 E0692 E0856
E0190 E0277 E0455 E0607 E0693 E0860
E0191 E0280 E0457 E0610 E0694 E0870
E0193 E0290 E0459 E0615 E0700 E0880
E0194 E0291 E0460 E0616 E0705 E0890
E0196 E0292 E0461 E0617 E0710 E0900
E0197 E0293 E0462 E0618 E0720 E0910
E0198 E0294 E0463 E0619 E0730 E0911
E0199 E0295 E0464 E0621 E0731 E0912
E0200 E0300 E0470 E0627 E0740 E0920
E0202 E0301 E0471 E0628 E0744 E0930
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 6
E0935 E0990 E1088 E1238 E1590 E2000
E0936 E0992 E1089 E1239 E1592 E2100
E0940 E0994 E1090 E1240 E1594 E2101
E0941 E0995 E1092 E1250 E1600 E2120
E0942 E1002 E1093 E1260 E1610 E2201
E0944 E1003 E1100 E1270 E1615 E2202
E0945 E1004 E1110 E1280 E1620 E2203
E0946 E1005 E1130 E1285 E1625 E2204
E0947 E1006 E1140 E1290 E1630 E2205
E0948 E1007 E1150 E1295 E1632 E2206
E0950 E1008 E1160 E1296 E1634 E2208
E0951 E1009 E1161 E1297 E1635 E2209
E0952 E1010 E1170 E1298 E1636 E2210
E0955 E1011 E1171 E1300 E1637 E2211
E0956 E1014 E1172 E1310 E1639 E2212
E0957 E1015 E1180 E1353 E1700 E2213
E0958 E1016 E1190 E1354 E1701 E2214
E0959 E1017 E1195 E1355 E1702 E2215
E0960 E1018 E1200 E1356 E1800 E2216
E0961 E1020 E1220 E1357 E1801 E2217
E0966 E1028 E1221 E1372 E1802 E2218
E0967 E1029 E1222 E1390 E1805 E2219
E0968 E1030 E1223 E1391 E1806 E2220
E0969 E1031 E1224 E1392 E1810 E2221
E0970 E1035 E1225 E1399 E1811 E2222
E0971 E1036 E1226 E1405 E1812 E2224
E0973 E1037 E1227 E1406 E1815 E2225
E0974 E1038 E1228 E1500 E1816 E2226
E0978 E1039 E1229 E1510 E1818 E2227
E0980 E1050 E1230 E1520 E1820 E2228
E0981 E1060 E1231 E1530 E1821 E2231
E0982 E1070 E1232 E1540 E1825 E2291
E0983 E1083 E1233 E1550 E1830 E2292
E0984 E1084 E1234 E1560 E1831 E2293
E0985 E1085 E1235 E1570 E1840 E2294
E0986 E1086 E1236 E1575 E1841 E2295
E0988 E1087 E1237 E1580 E1902 E2300
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 7
E2301 E2374 E2608 G0159 J0180 J1572
E2310 E2375 E2609 G0160 J0205 J1595
E2311 E2376 E2610 G0161 J0215 J1599
E2312 E2377 E2611 G0162 J0220 J1645
E2313 E2378 E2612 G0163 J0221 J1650
E2321 E2381 E2613 G0164 J0256 J1652
E2322 E2382 E2614 G0179 J0257 J1655
E2323 E2383 E2615 G0180 J0480 J1725
E2324 E2384 E2616 G0181 J0490 J1740
E2325 E2385 E2617 G0182 J0585 J1743
E2326 E2386 E2619 G0237 J0586 J1744
E2327 E2387 E2620 G0238 J0587 J1745
E2328 E2388 E2621 G0239 J0588 J1786
E2329 E2389 E2622 G0249 J0597 J1826
E2330 E2390 E2623 G0398 J0598 J1830
E2331 E2391 E2624 G0399 J0638 J1930
E2340 E2392 E2625 G0400 J0775 J1931
E2341 E2394 E2626 G0422 J0878 J1950
E2342 E2395 E2627 G0423 J0881 J2170
E2343 E2396 E2628 G0424 J0882 J2212
E2351 E2397 E2629 G0429 J0885 J2315
E2358 E2402 E2630 G0456 J0886 J2323
E2359 E2500 E2631 G0457 J0894 J2325
E2360 E2502 E2632 H0015 J0897 J2353
E2361 E2504 E2633 H0035 J1290 J2354
E2362 E2506 E8000 H0036 J1300 J2355
E2363 E2508 E8001 H0037 J1325 J2357
E2364 E2510 E8002 H0043 J1438 J2425
E2365 E2511 G0128 H0044 J1458 J2469
E2366 E2512 G0151 H2012 J1459 J2503
E2367 E2601 G0152 H2015 J1557 J2504
E2368 E2602 G0153 H2016 J1559 J2505
E2369 E2603 G0154 H2019 J1561 J2507
E2370 E2604 G0155 H2021 J1562 J2562
E2371 E2605 G0156 J0129 J1566 J2778
E2372 E2606 G0157 J0135 J1568 J2793
E2373 E2607 G0158 J0178 J1569 J2796
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 8
06 K0455 K0840 L0170 J2820 J9055 K00
J2941 J9155 K0007 K0462 K0841 L0172
J3110 J9171 K0009 K0606 K0842 L0174
J3262 J9179 K0010 K0669 K0843 L0180
J3285 J9201 K0011 K0672 K0848 L0190
J3300 J9202 K0012 K0730 K0849 L0200
J3315 J9206 K0014 K0738 K0850 L0450
J3357 J9207 K0015 K0739 K0851 L0452
J3385 J9212 K0017 K0743 K0852 L0454
J3396 J9213 K0018 K0800 K0853 L0456
J3472 J9214 K0019 K0801 K0854 L0458
J3473 J9215 K0020 K0802 K0855 L0460
J7178 J9216 K0037 K0806 K0856 L0462
J7186 J9217 K0038 K0807 K0857 L0464
J7312 J9218 K0039 K0808 K0858 L0466
J7315 J9219 K0040 K0812 K0859 L0468
J7321 J9225 K0041 K0813 K0860 L0470
J7323 J9226 K0042 K0814 K0861 L0472
J7324 J9228 K0043 K0815 K0862 L0480
J7325 J9261 K0044 K0816 K0863 L0482
J7326 J9263 K0045 K0820 K0864 L0484
J7525 J9264 K0046 K0821 K0868 L0486
J7632 J9265 K0047 K0822 K0869 L0488
J7686 J9302 K0050 K0823 K0870 L0490
J8562 J9303 K0051 K0824 K0871 L0491
J8565 J9305 K0052 K0825 K0877 L0492
J8650 J9307 K0053 K0826 K0878 L0621
J8705 J9310 K0056 K0827 K0879 L0622
J8999 J9315 K0065 K0828 K0880 L0623
J9015 J9328 K0069 K0829 K0884 L0624
J9019 J9330 K0070 K0830 K0885 L0625
J9025 J9355 K0071 K0831 K0886 L0626
J9033 K0001 K0072 K0835 K0890 L0627
J9035 K0002 K0073 K0836 K0891 L0628
J9041 K0003 K0077 K0837 K0898 L0629
J9042 K0004 K0105 K0838 L0112 L0630
J9043 K0005 K0108 K0839 L0113 L0631
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 9
L2220 L2540 L3204
L2230 L2550 L3206
L2232 L2570 L3207
L2240 L2580 L3212
L0632 L1652 L1980
L0633 L1660 L1990
L0634 L1680 L2000
L0635 L1685 L2005
L0636 L1686 L2010 L2250 L2600 L3213
L0637 L1690 L2020 L2260 L2610 L3214
L0638 L1700 L2030 L2265 L2620 L3215
L0639 L1710 L2034 L2270 L2622 L3216
L0640 L1720 L2035 L2275 L2624 L3217
L0700 L1730 L2036 L2280 L2627 L3219
L0710 L1755 L2037 L2300 L2628 L3221
L0810 L1831 L2038 L2310 L2630 L3222
L0820 L1832 L2040 L2320 L2640 L3224
L0830 L1834 L2050 L2330 L2650 L3225
L0859 L1836 L2060 L2335 L2660 L3230
L0861 L1840 L2070 L2340 L2670 L3250
L0974 L1843 L2080 L2350 L2680 L3251
L0976 L1844 L2090 L2360 L2750 L3252
L0978 L1845 L2106 L2370 L2755 L3253
L0980 L1846 L2108 L2375 L2760 L3254
L0982 L1847 L2112 L2380 L2768 L3255
L0984 L1850 L2114 L2385 L2780 L3257
L1000 L1860 L2116 L2387 L2785 L3260
L1001 L1900 L2126 L2390 L2795 L3265
L1005 L1902 L2128 L2395 L2800 L3500
L1200 L1904 L2132 L2397 L2810 L3510
L1210 L1906 L2134 L2405 L2820 L3520
L1220 L1907 L2136 L2415 L2830 L3530
L1230 L1910 L2180 L2425 L2840 L3540
L1300 L1932 L2182 L2430 L2850 L3550
L1310 L1940 L2184 L2492 L3140 L3560
L1600 L1945 L2186 L2500 L3150 L3570
L1610 L1950 L2188 L2510 L3160 L3580
L1620 L1951 L2190 L2520 L3170 L3590
L1630 L1960 L2192 L2525 L3201 L3595
L1640 L1970 L2200 L2526 L3202 L3600
L1650 L1971 L2210 L2530 L3203 L3610
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 10
L3620 L3962 L4398 L5570 L5651 L5702
L3630 L3967 L4631 L5580 L5652 L5703
L3640 L3971 L5000 L5585 L5653 L5704
L3649 L3973 L5010 L5590 L5654 L5705
L3671 L3975 L5020 L5595 L5655 L5706
L3674 L3976 L5050 L5600 L5656 L5707
L3677 L3977 L5060 L5610 L5658 L5710
L3702 L3978 L5100 L5611 L5661 L5711
L3720 L3980 L5105 L5613 L5665 L5712
L3730 L3982 L5150 L5614 L5666 L5714
L3740 L3984 L5160 L5616 L5668 L5716
L3760 L3995 L5200 L5617 L5670 L5718
L3762 L4000 L5210 L5618 L5671 L5722
L3763 L4002 L5220 L5620 L5672 L5724
L3764 L4010 L5230 L5622 L5673 L5726
L3765 L4020 L5250 L5624 L5676 L5728
L3766 L4030 L5270 L5626 L5677 L5780
L3806 L4040 L5280 L5628 L5678 L5781
L3808 L4045 L5301 L5629 L5679 L5782
L3900 L4050 L5312 L5630 L5680 L5785
L3901 L4055 L5321 L5631 L5681 L5790
L3904 L4060 L5331 L5632 L5682 L5795
L3905 L4070 L5341 L5634 L5683 L5810
L3906 L4080 L5400 L5636 L5684 L5811
L3913 L4090 L5410 L5637 L5685 L5812
L3915 L4100 L5420 L5638 L5686 L5814
L3919 L4110 L5430 L5639 L5688 L5816
L3921 L4130 L5450 L5640 L5690 L5818
L3925 L4205 L5460 L5642 L5692 L5822
L3927 L4210 L5500 L5643 L5694 L5824
L3929 L4350 L5505 L5644 L5695 L5826
L3931 L4360 L5510 L5645 L5696 L5828
L3933 L4370 L5520 L5646 L5697 L5830
L3935 L4386 L5530 L5647 L5698 L5840
L3956 L4392 L5535 L5648 L5699 L5845
L3960 L4394 L5540 L5649 L5700 L5848
L3961 L4396 L5560 L5650 L5701 L5850
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 11
L5855 L6020 L6615 L6690 L6945 L8300
L5856 L6025 L6616 L6691 L6950 L8310
L5857 L6050 L6620 L6692 L6955 L8320
L5858 L6055 L6621 L6693 L6960 L8330
L5859 L6100 L6623 L6694 L6965 L8500
L5910 L6110 L6624 L6695 L6970 L8501
L5920 L6120 L6625 L6696 L6975 L8505
L5925 L6130 L6628 L6697 L7007 L8507
L5930 L6200 L6629 L6698 L7008 L8509
L5940 L6205 L6630 L6703 L7009 L8510
L5950 L6250 L6632 L6704 L7040 L8511
L5960 L6300 L6635 L6706 L7045 L8512
L5961 L6310 L6637 L6707 L7170 L8513
L5962 L6320 L6638 L6708 L7180 L8514
L5964 L6350 L6640 L6709 L7181 L8515
L5966 L6360 L6641 L6715 L7185 L8603
L5968 L6370 L6642 L6721 L7186 L8604
L5970 L6380 L6645 L6722 L7190 L8605
L5971 L6382 L6646 L6805 L7191 L8614
L5972 L6384 L6647 L6810 L7260 L8623
L5973 L6386 L6648 L6880 L7261 L8624
L5974 L6388 L6650 L6881 L7360 L8627
L5975 L6400 L6655 L6882 L7362 L8628
L5976 L6450 L6660 L6883 L7364 L8629
L5978 L6500 L6665 L6884 L7366 Q0478
L5979 L6550 L6670 L6885 L7367 Q0479
L5980 L6570 L6672 L6890 L7368 Q2026
L5981 L6580 L6675 L6895 L7400 Q2043
L5982 L6582 L6676 L6900 L7401 Q4074
L5984 L6584 L6677 L6905 L7402 Q4081
L5985 L6586 L6680 L6910 L7403 Q4082
L5986 L6588 L6682 L6915 L7404 Q4100
L5987 L6590 L6684 L6920 L7405 Q4101
L5988 L6600 L6686 L6925 L7499 Q4102
L5990 L6605 L6687 L6930 L7510 Q4103
L6000 L6610 L6688 L6935 L7520 Q4104
L6010 L6611 L6689 L6940 L8035 Q4105
Anthem HealthKeepers Medicare-Medicaid Plan (MMP) Outpatient Services Requiring Prior Authorization
April 2014 Page 12
Q4106 Q5008 S5131 S9131 S9367 T1031
Q4107 Q5009 S5135 S9208 S9368 T1502
Q4108 S0145 S5136 S9209 S9370 T2022
Q4110 S0157 S5140 S9211 S9372 T2023
Q4111 S0255 S5141 S9212 S9373 T2024
Q4112 S1030 S5145 S9213 S9374 T2026
Q4113 S1031 S5146 S9214 S9375 T2027
Q4114 S1040 S5150 S9325 S9376 T2030
Q4115 S2053 S5151 S9326 S9377 T2031
Q4116 S2055 S5165 S9327 S9379 T2035
Q4117 S2060 S5170 S9328 S9472 T2042
Q4118 S2061 S5175 S9329 S9480 T2043
Q4119 S2065 S5180 S9330 S9490 T2044
Q4120 S2068 S5181 S9331 S9494 T2045
Q4121 S2102 S5497 S9335 S9497 T2046
Q4122 S2103 S5498 S9336 S9500 T2101
Q4123 S2140 S5501 S9338 S9501 V2625
Q4124 S2142 S5502 S9339 S9502 V2627
Q4125 S2150 S5517 S9340 S9503
Q4126 S2230 S5518 S9341 S9504
Q4127 S5035 S5520 S9342 S9529
Q4128 S5036 S5521 S9343 S9537
Q4129 S5100 S5522 S9345 S9538
Q4130 S5101 S5523 S9346 S9542
Q4131 S5102 S8037 S9347 S9558
Q4132 S5105 S8120 S9348 S9559
Q4133 S5108 S8121 S9349 S9560
Q4134 S5109 S9061 S9351 S9562
Q4135 S5110 S9097 S9353 S9590
Q4136 S5111 S9098 S9355 S9810
Q5001 S5115 S9122 S9357 T1000
Q5002 S5116 S9123 S9359 T1002
Q5003 S5120 S9124 S9361 T1003
Q5004 S5121 S9126 S9363 T1019
Q5005 S5125 S9127 S9364 T1021
Q5006 S5126 S9128 S9365 T1022
Q5007 S5130 S9129 S9366 T1030