The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2024.
The following codes have been added to the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:
V. Outpatient and DME Services: The following services require prior authorization:
5. Other services: 96547, 96548, 97037
The following codes have been removed from the Medicaid DME Authorization Grid and do not require prior authorization effective December 1, 2023:
K1036 Supplies for ultra diathermy
L1681 Ho bilateral hip abduction
L5991 Low pros ext osseo connector
The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grid and requires prior authorization:
C9159 prothrombin complex concentrate (human) (Balfaxar)
C9160 daxibotulinumtoxina-lanm
C9161 aflibercept hd
C9162 avacincaptad pegol
C9163 talquetamab-tgvs
C9164 cantharidin topical
C9165 elranatamab-bcmm
J0217 velmanase alfa-tycv
J0402 aripiprazole (Abilify asimtufii)
J0750 emtricitabine-tenofovir df, oral for PReP
J0751 emtricitabine-tenofovir alafenamide, oral for PReP
J0799 unclassified FDA approved PReP drugs
J1246 dinutuximab (Unituxin)
J1304 tofersen (Qalsody)
J1412 valoctocogene roxaparvovec-rvox (Rocavian)
J1413 delandistrogene moxeparvovec-rokl (Elevidys)
J2508 pegunigalsidase alfa-iwxj
J2799 risperidone (Uzedy)
J3401 beremagene geperpavec-svdt (Vyjuvek)
J9052 carmustine (Accord)
J9072 cyclophosphamide, (Dr. Reddy’s)
J9172 docetaxel (Ingenus)
J9255 methotrexate (Accord)
J9258 paclitaxel protein-bound particles (Teva)
J9286 glofitamab-gxbm (Columvi)
J9321 epcoritamab-bysp (Epkinly)
J9324 pemetrexed (Pemrydi RTU)
J9333 rozanolixizumab-noli (Rystiggo)
J9334 efgartigimod alfa and hyaluronidase-qvfc (Vyvgart Hytrulo)
Q0516 Pharmacy supplying fee for HIV pre-exposure prophylaxis fda approved prescription drug, per 30-days
Q0517 Pharmacy supplying fee for HIV pre-exposure prophylaxis fda approved prescription drug, per 60-days
Q0518 Pharmacy supplying fee for HIV pre-exposure prophylaxis fda approved prescription drug, per 90-days
Q5132 adalimumab-afzb (Abrilada)
Visit: Authorization Grids