4/30/2021
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective June 1, 2021.
The following services apply to Medicaid, Essential Plan, and Metal Level Plans and require prior authorization:
VIII. Pharmacy
Added:
S0012 butorphanol nasal
S0017 aminocaproic acid inj
S0020 bupivicaine inj
S0021 cefoperazone inj
S0034 ofloxacin inj
S0040 ticarcillin inj
S0074 cefotetan inj
S0078 fosphenytoin inj
S0080 pentamidine inj
S0081 piperacillin inj
S0088 imatinib oral
S0090 sildenafil oral
S0091 granisetron oral
S0104 zidovudine oral
S0106 bupropion SR, 60 tablets
S0108 mercaptopurine oral
S0109 methadone oral
S0117 tretinoin topical
S0119 ondansetron oral
S0132 ganirelix acetate inj
S0137 didanosine oral
S0138 finasteride oral
S0139 minoxidil oral
S0140 saquinavir oral
S0142 colistimethate inh
S0145 peg interferon alfa-2A
S0148 pegylated interferon alfa-2B
S0155 dilutant for epoprostenol
S0156 exemestane oral
S0157 becaplermin gel
S0160 dextroamphetamine oral
S0164 pantoprazole inj
S0169 calcitriol oral
S0170 anastrozole oral
S0172 chlorambucil oral
S0174 dolasetron oral
S0175 flutamide oral
S0176 hydroxyurea oral
S0177 levamisole oral
S0179 megestrol oral
S0182 procarbazine oral
S0183 prochlorperazine oral
S0187 tamoxifen citrate oral
S0194 vitamin suppl 100 caps
S0197 prenatal vitamins – 30 days
S4990 nicotine patches, legend
S4991 nicotine patches, non-legend
S4995 smoking cessation gum
S5000 prescription drug, generic
S5001 prescription drug, brand name
S9430 pharmacy compounding and dispensing services
The following services apply to Medicare Plans:
VIII. Pharmacy
Added (Medicare) – Requiring Authorization:
J0791 crizanlizumab (Adakveo)
J1429 golodirsen (Vyondys 53)
J1442 filgrastim (Neupogen)
J1447 tbo-filgrastim (Granix)
J2505 pegfilgrastim (Neulasta)
J2507 pegloticase (Krystexxa)
J2820 Sargramostim (Leukine)
J7312 dexamethasone intravitreal implant (Ozurdex)
J9177 Enfortumab vedotin-ejfv (Padcev)
J9355 trastuzumab (Herceptin)
J9356 trastuzumab hyal (Herceptin Hylecta)
Q5108 pegfilgrastim-jmdb (Fulphila)
Q5110 filgrastim-aafi (Nivestym)
Q5111 pegfilgrastim-cbqv (Udenyca)
Q5112 trastuzumab-dttb (Ontruzant)
Q5113 trastuzumab-pkrb (Herzuma)
Q5117 trastuzumab-anns (Kanjinti)
Q5122 pegfilgrastim-apg (Nyvepria)
Removed (Medicare):
C9061 teprotumumab-trbw, 10 mg (Tepezza)
C9062 daratumumab and hyaluronidase-fihj (Darzalex Faspro)
C9069 belantamab mafodontin-blmf (Blenrep)
C9070 tafasitamab-cxix (Monjuvi)
C9071 viltolarsen (Viltepso)
C9072 immune globulin (asceniv)
C9073 Brexucabtagene autoleucel (Tecartus)
C9122 Mometasone furoate sinus implant, 10 micrograms (Sinuva)
J2353 ocreotide (Sandostatin Depot)
J2354 ocreotide (Sandostatin subcutaneous)
J1930 lancreotide (somatuline depot)
Conditions Updated (Medicare):
J9035** bevacizumab (Avastin) Updated **authorization is not required for ophthalmic indications
Visit: Authorization Grids
COVID-19 UPDATE: Please refer to this link: Important Updates Regarding Coronavirus COVID-19, for authorization and coding guidelines related to the COVID-19 Pandemic.